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SURGICAL   OPERATIONS 


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Surgical  Operations  of  the  ^ead 

ILLUSTRATED     BT     CLIHICAL     OBSERVATIONS,     FOR 

PHYSICIANS  AND  SURGEONS 


BY 


Prof.    FEDOR    KRAUSE 

Privy  Medical  Councillor 
Directing  Physician  Augusta  Hospital,  Berlin,  m  associatuni  it'ith 

EMIL    HEYMANN,     M.D. 

chief  Physician,  Augusta  Hospital 
TRANSLATED  INTO  ENGLISH  AND  EDITED  FOR  AMERICAN  READERS  BY 

ALBERT  EHRENFRIED,  A.B.,  M.D.,  F.A.C.S. 

first  Assistant  Visiting  Surgeon,  Boston  City  Hospital;  Junior  Assistant  Surgeon, 
Children'.?  Hospital;  Surgeon,  Boston  Consumptives'  Hospital. 


2  VOLlJMES—983  PAGES 


1 1 1   PLATES  HAVING  606  COLOR  ILLUSTRATIONS 

and 

155   FIGURES  IN  THE  TEXT 


NEW  YORK 

ALLIED    BOOK    COMPANY 
17-25  WEST  60th  STREET 


■ft5<k:^#^^- 


COPYRIGHTED,  ALL 
RIGHTS    RESERVED 


Printed  In  America 


PREFACE 

For  many  years  it  has  been  my  intention  to  present  an  exposition 
of  the  operations  of  surgery  from  their  cUnical  aspect.  According  to 
this  plan,  each  individual  case  was  to  be  supplied  with  a  history,  a 
short  account  of  the  symptoms,  as  well  as  an  adequate  statement  of 
the  course  and  after-treatment,  and,  in  the  cases  which  ended  fatally, 
with  the  more  imiJortant  findings  from  tlie  autopsy  record.  The  pre- 
liminary labors  have  advanced  so  far  in  tlie  last  few  years  that  we  are 
now  approaching  tlie  completion  of  the  entire  work,  and  are  able  to 
present  to  the  public  the  first  section. 

Exact  protocols  of  the  various  operative  procedures  have  been  dic- 
tated by  me,  while  ]Max  Landsberg,  jjainter,  without  in  any  way  in- 
terrupting the  course  of  the  operation,  has  prepared  sketches  of  the 
different  steps.  Tliis  material  forms  the  foundation  for  a  representa- 
tion which,  as  I  l)e]icve,  will  be  jjractically  exhaustive  for  the  particular 
purpose  intended ;  for  the  extraordinary  variety  of  diseases  which  are 
met  with  in  the  Augusta  Hospital  offers  us  all  the  surgical  operations 
in  such  number  that  we  can  exercise  a  strict  choice.  At  the  same  time 
I  have  considered  it  a  duty  to  pviblish  an  inclusive  review  of  this  inter- 
esting material,  such  as  will  be  found  in  the  following  chapters. 

Since  I  hold  to  the  point  of  view  that  sjiecialization  in  surgery  should 
be  avoided,  if  one  desires  not  to  become  one-sided,  I  take  particular 
satisfaction  in  being  able  to  devote  my  career  to  a  hosjMtal  in  which, 
since  Ernst  Kiister's  effectual  work,  general  surgery  in  the  truest 
sense  of  the  term  has  been  practiced.  Even  those  operative  procedures 
which  for  a  long  time  have  been  separated  from  surgery  into  specialties 
of  their  own,  for  instance,  those  of  gynecology  and  those  of  aural 
surgery,  find  a  place  with  us.  For  that  reason  we  have  introduced  in 
addition  a  series  of  operations  on  the  female  organs  and  on  the  auditory 
apparatus,  in  so  far  as,  according  to  my  conviction,  every  hospital 
surgeon  is  confronted  by  them  and  nnist  be  in  a  jxisition  to  carry  them 
out. 

In  my  chief  ])hysieian  of  many  years'  standing.  Dr.  Emil  Ileymaim, 
1  have  found  an  experienced  collaborator,  who  has  given  me  great 
assistance  in  mastering  the  extensive  material,  and  who  is  accordingly 
associated  with  me  in  this  publication. 


bu'/ 


vi  FOREWORD 

The  purpose  of  the  book  consists  in  this,  that  it  offers  to  every 
properly  trained  physician  a  foundation  upon  which  he  can  indepen- 
dently undertake  the  operations  described.  In  order  to  fulfill  this 
purpose  in  all  its  details,  pictures  true  to  nature  explaining  the  dif- 
ferent phases  of  each  operation  have  been  liberally  supplied  on  special 
plates,  and  I  cannot  omit  expressing  my  particular  thanks  to  the  pub- 
lishers for  their  liberal  cooperation  in  this. 

As  the  work  not  only  includes  all  departments  of  surgical  therapy, 
but  also  takes  up  systematically  the  surgical  affections  in  the  manner 
in  which  they  are  considered  in  the  lecture  room,  it  may  also  be  prop- 
erly employed  as  a  text-book  by  students. 

Fedor  Krause. 

Berlin. 


FOREWORD  OF  THE  AMERICAN  EDITOR 

In  presenting  this  first  volume  of  the  Krause-Heymann  system  of 
operative  surgery  to  EngHsli-speaking  physicians,  a  word  of  intro- 
duction may  not  he  out  of  place.  Xaturally  an  undertaking  of  such 
magnitude  is  not  entered  into  without  mature  consideration,  and  par- 
ticularly in  face  of  the  fact  that  we  are  already  richly  suijplied  in  this 
country  with  text-books  and  manuals  of  surgery,  some  of  which  repre- 
sent a  high  grade  of  excellence. 

The  book  is,  primarily,  a  text-book  of  operative  surgery.  Its  pur- 
pose is  to  tell  how  to  operate,  and  it  fulfills  this  purpose  with  all  the 
exact  detail  for  which  the  German  mind  is  noted,  interpreted  by  a 
wealth  of  illustrations  surpassing  any  text-book  I  knoAv  of. 

It  approaches  its  subject  in  a  novel  way.  by  the  presentation  and 
discussion  of  actual  cases,  which  are  carefully  followed  from  the  be- 
ginning, through  the  operative  treatment,  to  the  end-result.  These 
cases  illuminate  the  text  and  give  a  touch  of  practical  interest  to  what 
might  otherwise  be  a  dry  discussion.  This  is,  in  fact,  an  application 
of  the  case-teaching  method  to  surgery. 

It  is  distinctly  a  personal  work,  dominated  by  the  genius  of  Fedor 
Krause,  whose  extensive  experience  over  the  entire  field  of  surgery, 
together  with  his  known  ability  as  a  teacher,  has  made  him  eminently 
fitted  for  the  task.  A  rich  supply  of  clinical  material  was  directly 
at  hand,  in  the  Augusta  Hospital.  But  the  presentation  is  by  no 
means  a  narrow  one;  various  methods  and  modifications  of  technique 
are  discussed,  their  advantages  compared,  and  the  reasons  given  why 
one  should  be  preferred  over  another. 

In  this  American  ada])tation  I  have  attempted  first  of  all  to  give 
an  accurate  transcrijjtion  of  the  German  text,  even  at  the  expense  of 
fluency.  I  have  modified  and  re-arranged  freely  wherever  it  seemed 
advisable.  ^Vhere  German  practice  differs  from  ours,  I  have  entirely 
rewritten  sections  and  paragraphs.  Technical  and  controversial  dis- 
cussions have  been  abridged;  new  matter,  illustrations,  and  cases  have 
been  added.  To  avoid  complicating  the  text,  no  attempt  has  been 
made  to  distinguish  the  alterations  and  additions. 

I  have,  in   short,  attempted  to  naturalize  this   German  book,  to 

adai)t  it  for  the  serious  study  of  the  American  student,  and  for  the 

reference  and  assistance  of  the  working  American  surgeon. 

„     ,  Albert  Ehrenfried. 

Boston. 


TABLE  OF  CONTENTS 


PART  I.— GENERAL  SURGICAL  TECHNIQUE 

CHAPTER  1  P^^ej. 

Preparation    for   Operation 1 

Kxaiiiinaliou    of    the    1'atii.iit 1 

General  Preparation 1 

Diet 1 

Narcotics 2 

Special  Preparation 3 

Medication 3 

Preparation  in  Diabetics 3 

Preparation  of  Special  Regions 5 

Contraindications  to   Operation 6 

The  OperatintT  Room 6 

Posture 7 

CHAPTER  2 

Anesthesia 10 

The  Special  Projurtics  of  Chloroform  and  Ether 10 

Sequela'  of  Chloroform  and  Ether 12 

Selection  of  the  Anesthetic 13 

Scopolaniin  and  Morphine  as  a  Preliminary  to  Anesthesia      ...  14 

Technique  of  Chloroform  Anesthesia 16 

Administration    of    Ether 18 

Ether   in   Elinor   Surjifery 20 

Nitrous   Oxide    (Gas) 22 

Ethyl  Chloride 24. 

Spinal  Anesthesia 24 

Local    Anesthesia 29 

Infiltration  and  Conduction  Anesthesia          30 

Cocain   and  Its  Substitutes 30 

Braun's   Procedure 32 

Advantafres  and  Disadvantages  of  Local  Anesthesia 33 

Anesthesia  of  the  Supei-ficial  and  Deej)  Tissues 36 

Blocking  of  Large  Nerve  Trunks 37 

Circuminjection  of  the  Vessels 37 

Circular  Injection  of  the  Soft  Parts  and  Bone 39 

Special    I'rocedures 39 

Laminectomy 40 

Tre])hining 40 

()])erations  on  the  Face 41 

Extremities 45 


X  TABLE  OF  CONTENTS 

CHAPTER  3  PAGE 

Asepsis 48 

Disinfection  of  the  Skin 49 

Clieniical   Cleansing 51 

Further  Rules  for  Asepsis  of  tlie  Skin 51 

Asepsis  of  the  Operative  Fieki 53 

Disinfection  of  the  Mucous  Membranes 55 

Sterilization  of  Instruments 56 

Sterilization  of  Dressings   and   Linen 57 

Impregnated  Gauze 58 

Sterilization   of   Suture   ]\Iaterial 59 

Employment  of  A'arious  Suture  Materials           60 

Sterilization  of  Catgut 61 

Sterilization  of  Silk  and  Linen 62 

Further  Aseptic  Regulations  during  Operation 63 

Draping  tlie  Patient 63 

Care  of  the  Wound 64 

Drainage 64 

Care  of  the  Wound  Edges 66 

CHAPTER  4 

After-Treatment 68 

Dressing 68 

Changing  the  Dressing 69 

Cardiac  Weakness 71 

Pain  in  the  Wound 73 

Thrombosis,  Embolus,  and  Pneumonia 73 

Gastric  and  Intestinal  Disturbances 74 

Artificial    Feeding 75 

Institution    of   Peristalsis 76 

CHAPTER  5 

Treatment  of  Wounds  of  the  Head          79 

Wounds  of  the  Soft  Parts 79 

Treatment  of  Compound  Fractures  of  the  Skull 80 

Bullet  Wounds  of  the  Skull 84 

Treatment   of  Infected   Wounds   and   Septic   Processes.     Incision    of 

Phlegmon 84 

Treatment  of  Furuncles 85 

Treatment  of  Carbuncle 88 

CHAPTER  6 

Extirpation  of  Tumors  in  the  Tissues  of  the  Face 91 

Small  and  Benign  Growths:    Lipoma,   Fibroma,  Sebaceous  Cysts        .  91 

Angioma   Cavernosum 92 

Racemose    Arterial    Hemangioma 93 

Extirpation  of  Large  or  Malignant  Tumors  of  the  Face     ....  96 


TABLE  OF  CONTENTS  xi 

CHAPTER  7  PAGE 

Plastic  Operation  on  the  Face             98 

Siinpk-   Mi'tliod-s  of  Dcnnoplasty 98 

Flap  (Jrufts 100 

Indian  .Mitliod 101 

Flap  Grafts  in  Other  Portions  of  the  Body 103 

The  Itahan  Method 104. 

Transphmtation  of  Free  Flaps 108 

Epidermal  Transplantation 108 

The  Wolfe-Krause  .Method 112 

Transplantation    of    Free    Flaps    After    Extirpation    of    Malignant 

Growths 117 

CHAPTER  8 

Special  Plastic    Procedures 121 

Plastic  Operations  on  the  Lips: 

Extirpation  of  Cancer  of  the  Lip 122 

Plastic  Restoration  of  the  Lip  from  the  Check  (Dieffenbach)   .       .       .  123 

Plastic  Operation  for  Harelip 127 

Plastic  Closure  of  Cleft  Palate 134 

Plastic  Operation   on   the   Nose 139 

Plastic  Operation  on  the  Cheeks l-iS 

CHAPTER  9 

Surgery  of  the  Eye  and  Orbit ISl. 

Enucleation  of  the  Bulb 154 

Exenteration  of  the  Orbit 156 

Exenteration   of  the  Orbit  with  Removal  of  the  Lid 157 

Krocnlein's  Osteoplastic  Resection  of  the  Temporal  Wall  of  the  Orbit  .  160 

Treatment  of  Cellulitis  of  the  Orbit 162 

CHAPTER  10 

Surgery  of  the  Ear         164 

Lijuries  and  Diseases  of  the  External  Ear 164 

Purulent  Litlammation  of  the  Middle  Ear 166 

Paracentesis 166 

Opening  Up  the  ]\Iastoid  Cells 167 

Opening  Up  the  Mastoid  Antrum 168 

Radical    0]>eration 171 

The  Plastic  Procedure  of  Panse-Korner 172 

Phlebitis  and  Thrombosis  of  the  Sigmoid  Sinus,  and  Ligature  of  the 

Jugular    ^'ein 174 

CHAPTER  11 

Surgery  of  the  Nose  and  the  Accessory  Sinuses 179 

Injuries  of  the  Nose 179 

Inflannnatorv  Diseases  of  the  Accessory  Sinuses 181 

Operations  on  the  Antrum 183 

Opening  Up  Both  Antra  After  the  Method  of  Partsch 185 


xii  TABLE  OF  CONTENTS 

PAGE 

Opening  Up  the  Frontal  Sinus 187 

Trephining  the  Anterior  Wall  of  the  Frontal  Sinus 187 

The  Uatiical  Operation  of  Killian 188 

Exj)osure  of  and  Radical  Operation  on  the  Ethmoid 190 

Exposure  of  the  Sphenoidal  Sinus 191 

Exposure   of   the   Sphenoidal    Sinus   and   the   Hypophysis   After  the 

Method  of  SchlofFer 191 

Killian's  Septum  Resection  and  the  Approach  to  the  Hypophysis  After 

the  Method  of  Hirsch 195 

CHAPTER  12 

Surgery  of  the  Trifacial  Nerve             197 

Neuralgic   Pains 197 

Painful  Points 197 

Irradiation 198 

Determination  of  the  Affected  Branch 199 

Accompanying  Manifestations 202 

The  Termination  of  Neuralgia  and  Relapses 202 

Neuralgia 203 

Diagnosis 203 

Prognosis 203 

Etiology 204 

Central  or  Peripheral  Seat 205 

General  Treatment 206 

Alcohol    Injections 207 

Peripheral   Operations          ' 208 

General  Anesthesia  and  Local  Anesthesia 208 

Indications 208 

Extraction    of    Nerves 209 

Result  and  Prognosis  of  Peripheral  Operation 212 

First  or  Ophthalmic  Division  of  the  Trifacial 213 

Resection  of  the  Frontal  Nerve 213 

Other  Branches  of  the  Oplithalmic  Division 215 

Second  or  Inferior  Maxillary  Division  of  the  Trifacial 217 

Resection   of  the   Infraorhital  Nerve 217 

Resection  of  the  Orbital    Nen-e 220 

Resection  of  the  Second  Division  at  tlie  Foramen  Rotundum  .       .       .  221 

A'ariations  in  Technique 224 

Third  or  Inferior  Maxillary  Division 227 

Resection   of  the   Lingual    Nerve 227 

Resection  of  the  Auriculo-Temporal    Nerve 228 

Resection  of  the  Inferior  Dental  and  Lingual  Nerve 229 

Modifications  in  Technique 233 

Resection  on  the  Third  Division  of  the  Foramen  Ovale 234 

Remarks  on  the  Resection  of  the  Second  and  Third  Divisions  at  the 

Base  of  the  Skull 236 

The  Simultaneous  Resection  of  the  Three  Divisions 238 


TABLE  OF  CONTENTS  xiii 

PAGE 

Extirpation  of  the  Gasserian  Ganglion 2ii9 

l'ri|)arati<)ii H-l^ 

Keratitis  Neuroparalvtica 24S 

Remarks  on  Technique 2-15 

Lifjation  of  tlie  Middle  Meninnfeal  Artery 2-i6 

Wiious  Ileiiiorrliaire S-i? 

^lanipiilation  of"  tlie  (iasscrian  Ganglion 247 

Care  of  the  Wound  and  After-Treatmenl 250 

Other  Methods  of  I^xtirpatinnf  the  Gasserian  Ganglion      ....  251 

Coni{)arison  of  the  A'arious  Methods 25-t 

Indications 255 

Intracranial  Resection  of  the  Tiiiid  Division 256 

Resection  of  the  Trifaci.il  Root 258 


LIST  OF  ILLUSTRATIONS  IN  THE  TEXT 

FIGURE  PAGE 

1     Local  Anesthesia  for  Extirpation  of  the  Gasserian  Ganglion  .       .      -iii 

13     Tension    Incisions 98 

1-1.     Mobilization  of  the  Flaps <)8 

15  &  16  A  Small,  Kectanfrnlar  Surface  Is  Coveredhy  a  Mobilized  Flap  .  !)8 
17  &  18  Large  Rectangular  Defects  Are  Covered  bv  Several  Flaps  .  .  99 
19  &  20     Three-Cornered  Defects  Are  Covered  by  a  Flap  Whicii  Is  I'oniRd 

by  a  Crescentic  Incision 99 

21  it  522      Large  Triangular  Defects  Are  Covered  by  a  Mobilization  of  the 

Wound  Edges  upon  Both  Sides 99 

Burrow's  Modification  for  Covering  Rectangular  Defects  .      99 

Burrow's  Modification  for  Covering  Rectangular  Defects  99 

F'orniation    of    Flap 101 

Turning  in  the  Flap 101 

Method    of    Taking    Reverdin    (irafts    from    Front    of    Thigh 

(Ehrenfried) 108 

Reverdin  Grafts  Planted  on  Raw  Surface  (Two-thirds  Natural 

Size)    (Ehrenfried) 109 

Extensive  Third  Degree  Burn  of  Neck,  (lust  and  Axilla  (l-'.hren- 

fried) 109 

Same  Case  as  Fig.  54  :  Photo  Takin  Twelve  Days  I^ater  .  .    110 

Upper  Lip  Restored  by  Transplantation  of  a  Free  Flap  from  the 

Flexor  Surfaces  of  the  Upper  Arm ll^ 

Photograph  Before  Operation,  Showing  Extensive  Lupus      .       .115 

Intermediate     Stage  ll(i 

Ajjpearancc  Nine  ^lonths  After  TraTisjjlantation       ....    117 

Nclaton's  Method  in  Incomplete  Harelip 128 

Graefe's  Method 128 

Malgaigne's  Method 128 

Sutures  Used  in  This  Method 128 

Mirault's  Method 129 

Dieffenbach's   Undulating    Incision 130 

Wolfe's  Zigzag    Incision 130 

Stitches  Introduced  in  Plastic  of  Palate .       .    13() 

Knots  in  the   Threads 137 

Stab  Needle  with  a  Curve  Like  a  Fi>hhook 138 

Langenbeck's  Lower  Lid  Technique 151 

Szynianowski's  ^Modification  of  Diefl';  iibach's  'l'echnir|ue   .  .    151 

Plastic  Operation   in  Ectr()|)ion 153 

The  lodges  of  the  Conjunctiva  United  with  Interru|)t('d  Sutures   155 

Outer  Wall  of  the  Orbit  Chiseled  Through Kit 

Area  of  Cortical  Bone  Chiseled  Away  in  Exposure  of  the  Tym- 
panic Antrum 170 

233     Trifacial  Nerve.    Schematic  Drawing  of  IN  Bi-anches  and  Their 

More  Important  Anastomoses  (After  Toldt )      .      .      .      .    200 

XV 


23  &  24 

25  it  26 

27 

28 

52 

53 

54 

55 

56 

57 

58 

59 

74&75 

76 

77 

78 

79  &  80 

81 

82  X:  83 

1 05 

106 

107 

158 

159 

160.Vlfil 

H)6 

184 

195 

xvi  LIST  OF  ILLUSTRATIONS  IN  TUE  TEXT 

FIGURE  PAGE 

23-i     Scheme  of  tlie  Distrihiitioii  of  the  Sensory  Nerves  of  the  Head, 

After   Fritz    Frohse     .....' 201 

235  I  Frontal  Nerve;  II  Infraorbital  Nerve 210 

236  Inferior  ]\Iaxillarv  Nerve  Exposed  by  Dividing  the  Ramus  of  the 

Jaw,  and  Twi'sted  After  the  Method  of  Thiersch  .       .       .       .211 
24^1      The  First  or  0})iitiialmic  Division  of  the  Trifacial  Nerve,  with 
the  Superior  Brancii  of  the  Oculomotor,  and  the  Trochlear, 
as  They  Appear  After  Removal  of  the  Orbit      ....    21-t 
2-i2     The  Second  or  Superior  Maxillary  Division  of  the  Trifacial,  with 
Its   Anastomosis   by   Two    Sphenopalatine   Nerves    with    the 
Sphenopalatine  Ganglion,  the  Superior  Dental  Nerves     .       .    216 
2-16     The  Dental  Branches  of  the  Superior  Maxillary  Nerve  .       .       .220 

255  Incisions  Through  Lvgoma 223 

256  The  Third  or  InfcrioV  Maxillary  Division  of  the  Trifacial   .       .    226 
263     The  Inferior  Dental  Nerve,  Its  Course  Through  the  Canal  of  the 

Lower  Jaw,  Its  Branches,  with  the  Inferior  Dental  Plexus 
and  Its  Terminal  Branch,  the  ^Mental  Nerve,  the  Buccinator 

Nerve 230 

268     Incisions  Through  Zygoma  and  Coronoid  Process  of  the  Jaw     .    235 

282  Operative  Field  for  Removal  of  the  Gasserian  Ganglion  After  F. 

Krause 249 

283  Doyen's  Older  Tcchnic— Incision 251 

284  Doyen'sOlderTechnic— Bony  Incision,  from  the  Side     .       .       .  252 

285  Doyen's  Older  Technic — Bony  Incision,  from  Below  ....  252 

286  Doyen's  Older  Technic — Exposure    of    the    Ganglion    and    Its 

'Branches 253 


LIST  OF  PLATES 

PLATK  PAGE 

1  Excision  of  a  Carbuncle  (Figs.  2  to  4) 88 

2  Excision  of  a  Cystic  Endothelioma  (Figs.  5  to  8) 91 

3  Angioma  Cavernosum  of  the  Cheek  I   (Fig.  9) 92 

4  Extirpation  of  an  Angioma  of  the  Cheek  II  (Figs.  10  to  12)     .  92 

5  Cutting  and  Implantation  of  a  IVdiculated  Flap  I  (Figs.  29  to  32)   .  102 

6  Cutting  and  Implantation  of  a  Pediculated  Flap  II  (Figs.  33  to  35).  102 

7  Pediculated  Flap  in  the  Region  of  Shoulder  and  Neck  (Figs.  36  to  39)  104 

8  Italian  Method  of  Rhinoplasty  I  (Figs.  40  to  43) 105 

9  Italian  Method  of  Rhinoplasty  II  (Figs.  44  to  46) 107 

10  Italian  .Method  of  Rhinoplasty  III  (Figs.  47  to  51) 107 

11  Transplantation  of  a  Free  Flap  to  the  Chin  (Figs.  60  to  63)      .       .    119 

12  Wedge  Excision  of  Cancer  of  the  Lip  (Figs.  64  to  68)    .       .       .       .    122 

13  Plastic  Restoration  of  Lip  from  the  Cheek  (Dieffenbach)   (Figs.  69 

to  73) 125 

14  Operation  for  Double  Harelip  (Figs.  84  to  93) 131 

15  Operation   for  Cleft  Palate  After  B.  von  Langenbeck  I   (Figs.  94 

to  96) 135 

16  Operation  for  Cleft  Palate  After  B.  von  Langenbeck  II  (Figs.  97 

to  104) 136 

17  Plastic  Closure  of  a  Cleft  Ala  Nasi  (Figs.  108  to  111)    .       .       .       .139 

18  Rhinoplasty:    Restoration  of  the  Ridge  of  the  Nose  by  Means  of  a 

Tibial" Transplant  (Lexer)  (Figs.  112  to  118)   .'   .       .       .       .142 

19  Plastic  Restoration  of  Sunken  Cheek  by  Free  Transplantation  of  Fat 

(Figs.  119  to  122)      .       .       .      ". 143 

20  Formationof  aColumnaof  the  Nose  (Figs.  123  tol28)  .       .       .       .144 

21  Plastic  Repair  of  Cheek  After  James  Israel  (Figs.  129  to  130)     .       .  146 

22  PlasticRepairof  Large  Defect  of  Face  I  (Figs.  131  to  135).       .       .  146 

23  PlasticRepairof  Large  Defect  of  Face  II  (Figs.  136  to  140)      .       .  148 

24  PlasticRepairof  Large  Defect  of  B'ace  III  (Figs.  141  to  144)    .       .  149 

25  PlasticRepairof  Large  Defect  of  Face  IV  (Figs.  145  to  148)     .       .  149 

26  PlasticRepairof  Large  Defect  of  Face  V  (Figs.  149  to  154)      .       .  150 

27  Plastic  Re{)air  from  Forehead  to  Correct  Contraction  of  Eyelid  and 

Formation  of  Eyebrow  (Figs.  155  to  157) 152 

28  Enucleation  of  the  Bulb  (Figs.  162  to  165) 153 

29  Exenteration  of  the  Orbit,  Retaining  the  Lids  (Figs.  167  to  171)      .    156 

30  Exenteration  of  the  Orbit,  with  Removal  of  Lids  I  (Figs.  172  to  175)    158 

31  Exenteration  and  Resection  of  Orbit  II  (Figs.  176  to  179)      .       .       .158 

32  Plastic  Covering  of  Exenterated  Ori)it  After  Kiister  III  (Figs.  180 

to  183) 159 

33  Kroenlein's  Osteoplastic  Resection  of  the  Temj)oral  Wall  of  the  Orbit 

(Figs.  185  to  188) 160 

34  Wedge-shaped  Resection  of  a  Portion  of  the  Shell  of  the  Ear  (Figs. 

189  to  192) 164 

35  Exposure  of  the  Mastoid  Cells  (Figs.  193  to  194) 168 

xvii 


xvlii  LIST  OF  PLATES 

PLATE  PAGE 

36  Exposure  of  the  Tympanic  Antrum  (Figs.  196  to  198)      .       .       .169 

37  Radical  Operation   in  Chronic  Purulent  Middle  Ear  Disease   (Hgs. 

199  to  203) ITl 

38  Radical    Mastoid:     The    Panse-Korner    ]\iethod    of    Plastic    Closure 

(Figs.  204.  to  209) 172 

39  Thrombophlebitis  of  the  Lateral  Sinus,  and  Ligature  of  the  Internal 

Jugular  Vein  (Figs.  210  to  212) 177 

iO     Opening  of  the  Antrum  of  Highmore  (Figs.  213  to  216)   ....    184- 

41  Radical  Operation  for  Double  Empyema  of  the  Antrum,  After  the 

Method  of  Partsch  (Figs.  217  "to  222) 185 

42  Radical  Operation  for  Infection  of  the  Frontal  Sinus,  After  Killian 

(Figs.  223  to  227) 188 

43  Exposure  of  Sphenoidal  Cells  and  Nasal  Approach  to  Hypophysis, 

After  Schloffer  (Figs.  228  to  232) 192 

44  Resection  of  the  Frontal  Nci-ve  (Figs.  237  to  240)  .       .       .       .•     .213 

45  Resection  of  the  Infraorbital  Nerve  (Figs.  243  to  245)      .       .       .    217 

46  Resection  of  the  Orbital  Nerve  (Figs.  247  to  250) 221 

47  Resection  of  the  Superior  Maxillary  Nerve  at  the  Foramen  Rotundum 

(Figs.  251  to  254) 222 

48  Resection   of  the  Lingual  Nerve  (Figs.  257  to  258) 227 

49  Resection   of  the  Auriculo-temporal  Nerve  (Figs.  259  to  262)    .       .    228 

50  Resection   of  the  Dental  and  Lingual  Nerves  (Figs.  264  to  267 )      .    231 

51  Resection  of  the  Inferior  INIaxillary   Nerve  at  the  Foramen   Ovale 

(Figs.  269  to  272) 234 

52  Extirpation  of  the  Ga.sserian  Ganglion  (Figs.  273  to  275)    .       .       .    239 

53  Extirpation  of  the  Gasserian  Ganglion  (Figs.  276  to  281)    .       .       .241 

54  Intracranial  Resection  of  the  Third  Division  (Figs.  287  to  290)  .       .    257 

55  Removal  of  the  Trifacial  Root  (Figs.  291  to  294) 258 


PART  I.  GENERAL  SURGICAL  TECHNIQUE 


CHAPTER  1— PREPARATION  FOR  OPERATION 

EXAMINATION"  OF  THE  PATIENT 

Preceding'  the  operation  a  routine  physical  examination  of  tlie 
patient  should  he  made,  in  order  to  anticipate  the  effects  of  the 
anesthetic  upon  the  organism,  to  take  measures  to  prevent  operative 
shock,  and  to  institute  any  necessary  drug  treatment.  Particular 
attention  should  he  paid  to  an  investigation  of  the  functional  ahility 
of  tile  heart  and  vascular  system,  the  kidneys  and  the  lungs.  Exam- 
ination of  the  urine  for  sugar  and  all)umen  should  never  he  omitted. 

GENERAL  PREPARATION 

On  the  evening  hefore  oj)eration,  the  patient  should  receive  a  warm 
hath  in  which  the  skin  is  scruhhed  with  soap  and  hrush,  and  the  finger 
and  toe-nails  cleaned.  This  precaution  is  omitted  only  when  the  patient's 
physical  condition  contra-indicates  it.  After  this  cleansing  bath,  the 
field  of  operation  is  shaved.  In  preparation  for  a  celiotomy  the  shaven 
area  should  extend  from  the  nipples  to  the  groins;  upon  the  limbs  to 
the  joint  above  and  l)elow.  In  operations  upon  the  brain  and  other 
procedures  on  the  skull,  the  scalp  shoidd  as  a  rule  be  competely  shaven. 
In  women,  however,  a  certain  amount  of  hair  may  be  allowed  to  remain 
in  order  to  prevent  mental  depression.  For  instance,  in  operations 
upon  the  cerebellum,  the  front  hair  may  be  pi-eserved.  Also  in  opera- 
tions upon  one  side  of  the  skull,  for  instance  upon  the  Gasserian 
ganglion,  the  otiier  half  of  the  skull  may  go  unshaven.  But  under 
no  circumstances  should  asepsis  be  endangered  out  of  regard  for  the 
wishes  of  the  patient.  On  account  of  the  inmimera])le  bacteria  which 
reside  in  tlie  scalp,  after  shaving  it  sliould  be  washed  with  ether  and 
a  dressing  of  1/.  per  cent,  foiiualin  applied,  to  be  removed  at  the 
beginning  of  the  operation. 

DIET 

On  general  principles  a  diet  should  be  selected  which  will  increase 
the  strength  and  well-being  of  the  patient  as  far  as  possible  in  the  days 
preceding  the  operation,  and  prevent  physical  weakness  after  the 

1 


2  PREPARATION  FOR  OPERATION 

operation.  The  food  should,  therefore,  be  nourishing  and  easily  digest- 
ible, and  of  a  sort  to  which  the  patient  is  accustomed.  A  sudden 
change  in  diet,  and  starvation,  even  in  affections  of  the  intestinal  track, 
is  useless  and  may  be  harmful.  Tobacco  and  liquor  should  not  be 
suddenly  withdrawn  in  persons  who  have  been  long  accustomed  to 
smoking  and  drinking,  for  sudden  abstinence  may,  in  conjimction 
with  operative  shock,  entail  a  dangerous  and  under  certain  circum- 
stances fatal  breakdown  in  the  strength  of  the  patient. 

Undernourished  and  fluid-starved  patients  should  receive  in  the 
days  preceding  the  operation,  twice  daily,  a  subcutaneous  injection 
of  about  one  quart  of  physiological  salt  solution,  with,  if  indicated, 
an  intramuscular  injection  of  one  or  two  c.c.  digalen.  Fluids  may 
be  introduced  into  the  body  also  by  means  of  enemata;  to  a  rectal 
injection  of  eight  ounces  of  salt  solution,  it  may  be  well  to  add  a  glass 
of  red  wine,  or  in  the  presence  of  diarrhoea,  from  10  to  20  drops  of 
tincture  of  opium.  Rectal  injections  may  be  less  conveniently  given 
by  the  drop  method,  and  in  certain  cases  nutritive  enemata  may  be  used. 

The  administration  of  fluids  is  particularly  indicated  in  patients 
with  stenosis  of  the  pylorus  and  dilated  stomach.  The  tetany  which 
occurs  as  the  result  of  inanition  and  the  drying  out  of  the  tissues  in 
these  cases  disappears,  as  a  rule,  as  the  fluid  balance  is  restored.  Occa- 
sionally patients  with  severe  trigeminal  neuralgia  must  receive  salt 
solution  or  nutritive  enemata  during  the  preparatory  period,  in  case 
they  have  almost  completely  stopped  eating  or  drinking  on  account 
of  pain,  as  not  infrequently  happens,  and  as  a  result  have  reached 
a  low  grade  of  vitality;  at  the  same  time  they  should  receive  morphine 
to  overcome  the  pain.  Ordinarily  the  administration  of  fluids  in  weak 
patients  exerts  a  favorable  influence  upon  the  action  of  the  heart, 
powerfully  increases  diuresis,  and  thus  promotes  elimination  of  the 
toxic  agents  which  have  assembled  in  the  bod}^  including  the 
anfBsthetic. 

On  the  day  of  the  operation,  as  a  rule,  the  patient  should  receive 
nothing  by  mouth,  except  perhaps  water  or  some  other  drink.  If  the 
operation  comes  late  in  the  day,  it  will  be  of  no  harm  for  children 
to  receive  a  glass  of  milk,  or  for  adults  to  take  a  little  tea,  a  cup  of 
broth,  or  a  glass  of  wine,  if  they  only  get  it  early. 

NARCOTICS 

In  order  to  help  a  nervous  patient  meet  the  sm-gical  procedure  with 
as  much  vigor  and  equanimity  as  possible,  he  should  receive  on  the 


SPECIAL  TREPARATIOX  S 

evening  before  the  operation  10  grains  of  veronal  in  hot  wine  or  tea. 
Morphine  should  be  given  if  on  account  of  severe  pain  the  milder  nar- 
cotic docs  not  work.  If  veronal  is  not  well  borne,  any  one  of  the  many 
sleep-inducing  agents,  such  as  sulphonal,  trional,  or  adalin,  may  be 
given  in  its  place.  In  children  a  narcotic  before  the  operation  is  given 
under  exceptional  circumstances  only. 


SPECIAL  PREPARATION 

MEDICATION' 

In  emergency  operations  and  in  the  majority  of  other  operations 
special  preparation  of  the  system  by  means  of  drugs  is  unnecessary. 
The  administration  by  mouth  or  subcutaneous  injection  of  drugs  for 
the  disinfection  of  the  tissues,  of  the  gastro-intestinal  track  or  other 
organs  in  order  to  increase  their  resistance  to  infection  is  ordinarily 
useless.  ^Vhen  physical  examination  shows  the  necessity  thereof,  the 
patient  should  be  given  a  course  of  drug  treatment  for  several  days 
or  longer,  preceding  the  operation.  Patients  with  cardiac  insufficiency 
should  be  given  some  digitalis  preparation,  and  those  with  nervous 
disturbances,  such  as  epileptics  and  persons  with  exophthahnic  goiter, 
should  receive  potassium  bromide  or  some  other  sedative.  Patients 
with  bronchitis  should  be  assisted  in  the  solution  and  riddance  of  the 
secretion  by  the  administration  of  expectorants.  In  dry  catarrh  the 
irritative  cough  should  be  controlled  by  means  of  codein  and  similar 
drugs.  Patients  with  jaundice  are  given  for  several  days  4.5  grains 
of  calcium  chlorate  per  day  in  order  to  increase  the  coagulability  of 
the  cholemic  blood. 

PREPARATION  IX  niABETICS 

Careful  attention  should  be  given  to  the  preparation  of  patients 
with  diabetes.  It  is  recognized  that  in  diabetics  even  slight  wounds 
on  the  extremities  easily  lead  to  infection  and  j)ossibly  gangrene  of  tlie 
entire  limb.  Tlie  cause  of  this  is  the  sugar  and  allied  acids  contained 
in  the  tissues,  in  conjunction  with  the  arteriosclerosis  which  always 
co-exists  in  a  greater  or  less  degree.  The  presence  of  these  elements 
will  be  recognized  by  examination  of  the  in"ine.  and  whether  sugar  is 
present  alone  or  with  acetone,  precautions  should  always  be  taken. 
In  emergency  operations,  to  be  sure,  such  as  acute  api)endicitis,  time 
does  not  allow,  but  in  any  case,  before  or  immediately  after  the  opera- 


4  PREPARATION  FOR  OPERATION' 

tion  attempts  should  be  made  to  bi'ing  about  at  least  a  diminution 
in  the  sugar  or  acid  saturation  of  the  tissues. 

If  a  low  grade  of  diabetes  is  present,  with  little  sugar  and  without 
acetone  or  diacetic  acid  in  tlie  urine,  the  patient  should  be  carried 
along  on  a  diet  free  of  carbohydrates  until  the  last  traces  of  sugar 
have  disappeared  before  the  operation  is  inidertaken. 

If  the  patient  presents  a  severe  grade  of  diabetes,  therapeutic 
measures  will  depend  upon  the  results  of  the  antidiabetic  diet,  and  the 
lu-inary  findings.  Either  a  large  amount  of  sugar  is  being  eliminated 
and  the  quantity  is  not  decreased  under  absolute  dietary  restrictions, 
or  in  addition  to  sugar  acetone  is  present  in  the  urine.  In  the  first 
case  the  limitation  of  carbohydrates  before  ojieration  is  only  carried 
so  far  as  the  patient  can  stand  without  weakening.  A  small  remnant 
of  glycosuria  before  operation  is  less  dangerous  than  an  extreme  reduc- 
tion of  the  body  resistance  by  an  otherwise  advantageous  diet. 

In  the  other  form  of  severe  diabetes,  in  which  the  sugar  excretion 
is  combined  with  the  excretion  of  acetone  or  diacetic  acid,  therapeutic 
measiH'es  will  depend  upon  whether  the  acids  appear  in  the  lu-ine  only 
after  the  withdrawal  of  carbohydrates  from  the  diet,  or  if  they  dimin- 
ish simultaneously  with  the  sugar,  or  if  they  increase  in  spite  of  the 
deprivation  of  carbohydrates.  If  the  acetone  first  appears  wliile  the 
sugar  is  decreasing  in  the  lu'ine,  the  strict  diet  luust  be  relieved  until 
the  acetone  has  disajipeared,  for  the  presence  of  these  acids  in  the 
tissues  will  interfere  more  with  wound  healing  than  the  presence  of 
sugar.  The  outlook  for  wound  healing  is  more  favorable  if  the  acetone 
and  the  sugar  disappear  simultaneously,  for  a  severe  diabetes  may  in 
such  cases  for  a  considerable  time  at  least  be  converted  into  a  mild 
form,  with  the  help  of  dietary  restrictions.  At  the  same  time  one 
should  be  sin-e  in  these  cases  that  too  great  an  inroad  into  the  patient's 
vitality  be  not  allowed. 

The  prognosis  is  worst  when  the  elimination  of  acids  cannot  be 
influenced  in  spite  of  the  withdrawal  of  carbohydrates.  In  these 
•cases  diabetic  coma  is  a  threatening  danger.  All  precautions  should 
be  directed  to  the  neutralizing  of  the  acids  which  are  present  in  the 
body,  and  for  this  purpose  the  patient  should  receive  large  quantities 
of  sodium  bicarbonate,  in  teaspoonfid  doses  by  mouth,  and  by  rectal 
injection  with  opium,  to  the  amount  of  three  ounces  per  day.  If  coma 
appears  intravenous  injections  of  5  per  cent,  soda  bicarbonate  solution 
may  be  given,  and  it  shoidd  be  continued  until  tlie  lu-ine  shows  an 
alkaline  reaction.    Von  Xoorden  advises  in  the  case  of  increasing  acid 


PREPARATinX  OF  SPECIAL  REGIONS  5 

elimination  and  threatening  coma  in  spite  of  comjjlete  abstention  from 
carboliydnitcs,  to  interrupt  tlie  diet  temporarily  by  the  administration 
of  oat-meal.  Umber  recommends  the  simultaneous  administration  of 
large  doses  of  morphine  or  opium,  by  means  of  which  the  distressing 
thirst  is  also  controlled. 

PREPARATIOX   Ol'  SPECIAI,   KECIOXS 

Before  anesthesia  is  started,  the  mouth  should  be  M'ashed  out  with 
4  per  cent,  boric  acid  solution  or  2  per  cent,  hydrogen  dioxide,  and  the 
teeth  should  be  mechanically  cleaned  with  a  tooth  brush.  In  this  way 
the  bacterial  flora  of  the  mouth  is  diminished,  and  the  possibiHties  of 
infection  of  wounds  in  the  mouth  and  tongue  incurred  during  anes- 
thetization, and  of  infection  of  the  respiratory  track,  are  lessened. 

Irrigation  of  the  bladder  is  performed  preceding  operation  on  the 
lu'inary  organs  only  in  the  ])resence  of  cystitis.  A  2  per  cent,  boric  acid 
solution  or  a  one  to  two  thousand  or  one  thousand  solution  of  corrosive 
sublimate  may  be  used.  In  every  case  it  is  of  advantage  to  promote 
diuresis  by  taking  non-carbonated  waters,  reinforced  by  urotropine, 
which  may  be  given  vip  to  seventy-five  grains  per  day.  In  addition 
eveiy  patient  should  empty  the  bladder  before  operation,  for  a  full 
bladder  may  be  a  source  of  trouble  during  a  celiotomy,  and  if  it  is 
emptied  during  the  operation,  either  spontaneously  or  by  means  of  a 
catheter,  asepsis  is  disturbed.  Before  gynecological  operations,  the 
vagina  should  be  washed  out  with  alcohol,  boric  acid  solulioTi,  or  lysol. 

Evacuation  of  the  stomach  followed  by  lavage  is  indicated  only  when 
it  is  difficult  or  impossible  for  the  stomach,  on  account  of  narrowing 
of  the  pylorus  through  scar  contraction  or  new  growth,  to  empty  itself. 
In  every  operation  on  the  stomach  or  duodenum  the  retained  and  par- 
tially digested  food  should  be  washed  out  through  a  stomach  tube  with 
a  solution  of  warm  water,  .'3  per  cent,  boric  acid,  soda  bicarbonate  or 
one  to  two  thousand  corrosive.  The  irrigation  must  be  continued  until 
the  water  comes  back  clean.  This  precaution  should  never  be  omitted 
if  it  is  probable  that  the  stomach  contents  may  be  inspired  durhig 
vomiting  in  the  course  of  or  after  the  an;estliesia,  for  instance,  in  the 
presence  of  intestinal  obstruction,  or  in  emergency  operations  which 
are  undertaken  shortly  after  a  meal. 

On  the  day  before  the  operation  care  must  be  taken  that  the  intes- 
tines are  well  cleaned  out.  Frequently  assistance  must  be  given  by 
means  of  castor  oil,  Carlsl)ad  salts,  or  an  enema.  Only  mild  laxatives 
should  be  used,  in  order  that  the  patient  be  not  minecessarily  weakened 


6  PREPARATION  FOR  OPERATION 

through  diarrhoea.  This  precaution  should  be  taken  before  operation 
not  only  to  increase  the  comfort  of  the  patient,  but  in  order  that  it 
shall  not  become  necessary  to  take  measures  soon  after  the  operation, 
for  with  the  effort  necessary  to  bowel  movement  a  freshly  operated 
case  may  be  placed  in  some  danger.  Also  after  operations  upon  the 
jjeritoneal  cavity,  the  belly  muscles  are  weakened  from  the  incision, 
and  normal  bowel  activity  is  interfered  with;  and  on  accoimt  of  the 
intestinal  paresis  which  follows  celiotomies,  with  the  resulting  danger 
of  toxic  absorption,  a  previous  catharsis  is  necessary.  In  particidar 
the  lower  bowel  should  be  emptied  because  it  frequently  has  to  be 
employed  in  the  first  days  after  the  operation  for  the  administration 
of  drugs  and  means  of  nutrition. 

CONTRA-INDICATIONS  TO  OPERATION 

A  contra-indication  to  the  carrying  out  of  any  necessary  operation 
can  only  be  established  on  pressing  grounds,  after  a  careful  investi- 
gation of  the  entire  system.  Neither  extreme  age  nor  early  infancy 
is  to  be  considered  a  hindrance.  Weak  and  exhausted  patients  are  at 
the  present  day  anesthetised  by  such  gentle  and  harmless  means  that 
the  attempt  to  bring  operative  assistance  should  always  be  given 
weight  against  sure  death.  Obese  and  very  anemic  patients,  diabetics 
and  leukemics  appear  to  be  particularly  endangered  by  major  pro- 
cedures. 

During  menstruation  operations  upon  the  genitalia  and  in  their 
neighborhood  shoidd  be  avoided,  unless  delay  is  dangerous.  Likewise 
in  pregnancy,  unless  some  special  indication  exists,  the  operation 
should  be  postponed  until  after  delivery. 

In  the  presence  of  hemophilia  only  the  most  urgent  operations 
should  be  undertaken.  Before  every  operation  one  should  protect 
himself  against  error  in  this  respect  by  a  careful  history.  Preparatory 
treatment  by  means  of  hydrastis  or  gelatin  (by  rectal  or  subcutaneous 
injection  or  as  an  addition  to  the  food) ,  and  by  injections  of  a  foreign 
serum  (diphtheria  antitoxin)  may  be  of  great  advantage  in  increasing 
the  coagulability  of  blood. 

THE  OPERATING   ROOM 

For  an  operating  room  any  room  with  sufficient  natural  or  artificial 
light  may  be  used  on  occasion.  The  one  necessary  condition  is  that 
it  should  be  free  of  dust.  For  that  reason  a  room  without  curtains, 
hangings,  carpets  and  similar  dust  retainers  should  be  chosen.    In  any 


POSTURE  7 

case  such  furnishings  should  not  be  disturbed  immediately  before  the 
operation.  The  floor  should  be  carefully  wiped  with  a  moist  cloth,  but 
not  dry  swept.  For  major  operations  an  operating  room  completely 
equi])ped  and  with  a  good  statt"  of  attendants  is  preferable  to  any 
makeshift.  In  case  of  necessity  a  single  flat  kitchen  table  may  be  used 
for  an  operating  table.  For  hospital  use  special  models  have  been 
developed  in  Germany,  which  are  built  entirely  of  metal  and  stand 
solid  upon  a  central  pedestal;  they  may  be  thoroughly  cleansed  and 
their  various  parts  readily  adjusted.  The  top  of  this  table  may,  by 
means  of  an  oil  pump,  be  raised  or  lowered  on  a  level  or  it  may  be  tilted 
to  either  side  or  lowered  at  either  end.  The  typical  American  table 
stands  upon  four  legs  and  has  a  sectional  top  of  glass  or  enameled 
steel.  The  leg  section  may  be  folded  down,  or  the  head  section  lifted, 
and  the  table  as  a  whole  may  be  tilted  by  means  of  a  crank  so  that  the 
head  is  depressed  and  the  foot  elevated. 

POSTURE 

The  patient  is  to  be  placed  in  the  position  which  best  facilitates 
approach  to  the  field  of  operation.  At  the  same  time  respiration  or 
cardiac  activity  should  not  be  interfered  with  by  compression  of  chest 
or  abdomen. 

Procedures  on  the  front  of  the  body  are  customarily  carried  out 
with  the  patient  u})on  his  back,  whether  they  involve  the  head,  trunk 
or  extremities.  The  head  of  the  patient  lies  upon  the  same  level  as 
the  body,  or.  better  still,  is  carried  slightly  backwards  in  order  to  make 
it  easier  for  the  anesthetist  to  lift  up  the  lower  jaw  and  pull  forward 
the  tongue  in  case  the  airway  is  obstructed.  The  arms  lie  ordinarily 
at  the  side  of  the  patient.  For  celiotomies,  involving  the  lower  portion 
of  the  abdomen,  the  forearms  may  be  carried  across  the  thorax,  and 
held  rolled  uj)  in  the  patient's  night-gown;  for  o])crations  in  the  upper 
portion  of  the  abdominal  cavity  the  hands  are  laid  flat,  palm  down- 
ward, under  the  buttocks  on  either  side.  Care  is  to  be  taken  that  one 
of  the  arms  does  not  hang  over  the  edge  of  the  table,  as  paralysis  may 
result.  The  anesthetist  follows  the  pulse  by  palpation  of  the  facial  or 
temporal  artery,  or  In'  stethosco])e  strapped  to  the  precordium. 

Trendelenburg's  position,  which  consists  of  an  elevation  of  the  pelvis 
with  the  knees  bent,  is  employed  in  all  abdominal  gynecological  opera- 
tions, in  operative  procedures  on  the  bladder,  and  upon  the  lower  seg- 
ment of  the  colon.  The  legs  are  tied  down,  to  prevent  the  patient 
from  slij)i)ing.    Its  advantage  lies  in  the  fact  that  the  small  intesthies 


8  PREPARATION  FOR  OPERATION 

and  the  omentum  are  carried  by  gravity  into  the  upper  portion  of  the 
peritoneal  cavity  and  do  not  interfere  with  the  operation.  Patients 
witli  arteriosclerosis  should  not  l)e  kept  too  long  in  this  position, 
because  the  blood  pressure  within  the  cranium  may  be  increased  to 
dangerous  proportions.  This  holds  true  also  for  old  persons  with 
prostatic  hypertrophy.  In  every  case  the  horizontal  position  should 
be  restored  as  early  as  possible,  at  any  rate  before  one  starts  sewing 
up  the  abdominal  Avail.  The  stomach  and  intestines  fall  at  once  into 
their  original  position,  but  the  omentum  is  apt  to  remain  in  the  upper 
portion  of  the  peritoneal  cavity.  Accordingly  at  the  end  of  the 
operation  the  omentum  should  be  unfolded  and  draAATi  do\\Ti  over  the 
intestines.  If  this  is  omitted,  serious  circulatory  disturbances  may 
take  place  in  the  omentum,  and  symptoms  of  obstruction  may  appear 
in  the  rolled  up,  and  possibly  kinked  off,  transverse  colon. 

In  the  lithotomy  position  the  patient,  placed  upon  his  back,  is  pulled 
dowTi  until  the  buttocks  project  beyond  the  end  of  the  table.  Both 
legs  are  held  flexed  at  the  hips,  either  by  assistants,  or  in  leg-holders 
which  attach  to  the  lower  end  of  the  table.  This  position  is  necessary 
in  operations  upon  the  anus  and  rectum  and  in  gynecological  opera- 
tions through  the  vagina. 

Tlie  lateral  position  is  employed  in  operations  upon  the  thorax,  the 
kidneys  and  ureters,  and  the  hip  joint.  If  possible  the  patient  should 
be  jjlaced  upon  his  right  side,  as  in  this  position  the  heart  is  less  re- 
stricted. As  in  the  Sims  position  the  under  arm  is  drawii  through  to 
the  back,  to  prevent  pressure  paralysis,  and  the  upper  leg  is  sharply 
flexed  at  the  hip  and  knee.  A  pillow  or  bolster  is  placed  in  front  of 
the  thorax.  In  operations  upon  the  cerebellum,  the  sjiine,  cord  and 
the  back  generally  the  patient  lies  flat  on  his  stomach,  with  tlie  head 
projecting  beyond  the  table  to  facilitate  etherization.  The  forehead  is 
supported  bv  the  lap  of  the  anesthetist,  or  by  a  specially  constructed 
frame. 

In  operations  upon  the  skull  and  face  the  patient  may  advanta- 
geously be  placed  in  a  half  sitting  posture,  as  in  this  way  the  flow  of 
blood  is  better  controlled.  The  head  is  held  by  an  assistant  with  both 
hands,  by  whom  it  may  be  moved  forward  or  backward,  rotated,  or 
laid  on  tlie  shoulder  at  will. 

Pillows,  rolls  and  sand  bags  of  various  shapes  and  sizes  may  often 
be  used  to  advantage.  With  a  small  sand  bag  one  may  raise  when 
necessary  certain  parts  of  the  body,  and  it  is  particularly  useful  in 
supporting  a  limb  upon  which  chisel  and  mallet  are  to  be  used.    Hard 


POSTURE  9 

stuffed  rolls  may  be  shoved  under  the  shoulders,  in  operations  upon 
the  neck,  to  allow  the  head  to  hang  back  and  thus  put  the  soft  parts 
of  the  neck  on  the  stretch.  In  operations  upon  the  lower  thorax,  to 
increase  the  lateral  flexure  and  widen  the  apertuie  between  the  ribs, 
a  pad  may  be  placed  under  the  side.  In  operations  upon  the  gall- 
bladder and  bile  ducts,  a  sand-bag  or  roll  is  placed  under  the  back 
in  the  region  of  the  diaphragm  to  facilitate  exposure.  For  these 
purposes  as  well  as  for  kidney  operating  the  Cunningham  elevator  is 
of  great  convenience. 

Paralysis  may  occur  in  the  arm  or  leg  as  the  residt  of  pressure 
during  the  operation.  It  is  more  common  in  the  arm;  if  the  arm  hangs 
to  one  side  the  musculo-spiral  nerve  is  pressed  between  the  humerus 
and  the  edge  of  the  table,  or  if  it  is  held  high  above  the  head  or  lies 
under  the  body  in  the  lateral  posture,  the  brachial  plexus  may  be 
squeezed  between  the  clavicle  and  the  first  rib.  In  the  leg  the  peroneal 
nerve  is  most  apt  to  be  involved,  although  jicroneal  paralysis  occurs 
comparatively  infrequently.  Insufficient  j)adding  of  the  leg  holder 
causes  pressure  of  the  nerve  against  the  head  of  the  fibula. 

In  order  to  avoid  serious  cooling  of  the  body  surfaces  of  the  exposed 
patient  the  operating  room  must  be  as  warm  as  may  conveniently  be 
borne  by  the  operator  and  his  staff'.  All  i)ortions  of  the  body  which 
lie  outside  of  the  operative  field  should  be  wrajjped  in  woolen  cover- 
ings. In  celiotomies  and  perineal  operations  each  leg  should  be  com- 
pletely encased  in  a  flannel  boot,  and  the  chest  and  shoulders  also 
well  covered.  It  is  best  to  leave  the  coverings,  if  they  are  still  dry, 
upon  the  body  of  the  patient  after  the  operation,  particularly  if  he  has 
perspired  freely,  and  to  remove  them  oidy  after  the  patient  has  been 
transferred  to  a  previously  warmed  bed. 


CHAPTER  2— ANESTHESIA 

In  order  to  carry  through  major  operations  without  pain  we  ordi- 
narily employ  inhalation  anesthesia,  less  frequently  spinal  and  local 
anesthesia.  The  results  with  intra-venous  and  rectal  anesthesia  have 
not  yet  justified  their  general  adoption.  For  inhalation  chloroform, 
ether  and  nitrous  oxide  or  some  combination  of  these  are  used,  accord- 
ing to  the  indications,  and  the  experience  and  preference  of  the 
surgeon. 

Inhalation  anesthesia  is  ordinarily  without  danger  Avith  any  of  these 
agents,  if  overseen  by  a  careful  and  experienced  anesthetist.  But  over 
against  its  beneficence  for  the  patient  and  its  ad\'antages  for  the 
operator  have  to  be  placed  the  possibility  of  danger  to  the  patient, 
during  the  administration,  or  from  the  subsequent  effects.  These 
depend  chiefly  on  the  fact  that  the  patient  during  the  anesthesia  is 
absorbing  a  poison,  and  that  the  loss  of  sensibility  to  pain  is  onlj^  one 
manifestation  of  a  general  intoxication. 

THE  SPECIAL  PROPERTIES  OF  CHLOROFORM  AND  ETHER 

The  activity  of  both  these  agents  depends  upon  the  fact  that  the 
inhaled  vapor,  carried  by  the  blood,  invades  all  the  tissues  and  pene- 
trates to  the  cells  of  the  cortex.  In  order  to  induce  narcosis  the  sensory 
paths  and  the  cortex  must  be  overcome.  For  even  in  comparatively 
deep  anesthesia  the  motor  paths  from  the  cortex  are  active,  as  may  be 
shown  by  electric  stimulation  of  the  motor  region  during  an  operation 
for  the  relief  of  epilepsy.  Also  the  jieripheral  portions  of  the  motor 
tracks  always  respond  to  stimulation  in  spite  of  deep  narcosis,  as  may 
be  seen  by  the  contraction  of  a  muscle  which  results  when  a  motor 
nerve  is  touched.  The  cerebellum  is  afi'ected  earlier  than  the  cerebrum, 
for  at  the  beginning  while  consciousness  still  persists,  there  appears 
a  high  grade  of  ataxia,  similar  to  that  resulting  from  alcoholic  in- 
toxication. 

In  order  to  completely  overcome  the  motor  tracks  large  quantities 
of  the  anesthetic  are  necessary.  Such  a  motor  paralysis  involves  con- 
siderable danger,  particularly  as  paralysis  of  the  nerves  in  the  pons 
and  medulla  is  synonymous  with  respiratory  and  cardiac  paralysis. 
This  condition  appears  only  when  large  quantities  of  pure  vapor  are 

10 


chlorofor:m  and  ether  ii 

given  unmixed  with  air.  The  loss  of  motility  of  voluntary  muscles 
during  anesthesia  depends  upon  the  paralysis  of  the  cortex  and  of 
the  will  power,  and  destruction  of  the  reflexes  depends  upon  the 
paralysis  of  the  sensory  portion  of  the  reflex  arc. 

Since  chloroform  and  ether  are  toxic  the  quantity  used  is  of  signifi- 
cance in  relation  to  their  injurious  effects.  Ordinarily  a  considerable 
amount  of  ether  may  he  necessary  to  induce  anesthesia,  quantitatively 
considerably  more  than  chloroform,  but  as  the  operation  proceeds  the 
amount  of  ether  which  is  necessarj'  decreases,  and  at  the  same  time 
the  danger  of  respiratory  paralysis. 

Coincident  with  the  poisoning  of  the  central  nervous  system  injuri- 
ous efl"ccts  are  produced  upon  other  tissues  and  organs.  The  toxic 
influence  of  either  agent  may  become  apparent  in  its  most  dangerous 
form  at  the  begimiing  of  its  absorption,  as  in  the  cases  of  sudden  death 
at  the  beginning  of  the  anesthesia.  This  sort  of  toxic  effect  occurs 
usually  in  patients  with  status  thymicus  or  lymphaticus.  In  their 
later  toxic  symptoms  the  two  agents  diff'er  from  each  other.  Chloro- 
form works  an  injurious  effect  upon  the  heart  muscle  in  smaller  quan- 
tities than  ether,  but  the  effect  upon  the  kidneys  is  more  prolonged 
in  the  case  of  ether  than  in  the  case  of  chloroform.  The  small  traces 
of  aU)umin  in  the  first  few  days  after  chloroform  anesthesia  usually 
disaj)i)ear  rapidly,  while  lU'emic  symptoms  are  sometimes  met  with 
after  a  long  ether  anesthesia.  The  parenchyma  of  the  liver  is  more 
seriously  damaged  by  chloroform,  and  fatty  denegeration  and  general 
icterus  are  not  infrequent  sequelas.  After  etherization  the  coagula- 
bility of  the  blood  is  decreased. 

The  effect  of  ether  upon  the  mucous  membranes  is  its  most  serious 
drawback.  While  irritation  of  the  nuicous  mem})rane  of  the  stomach 
and  intestines  seems  to  be  without  harmful  results,  except  as  it  occa- 
sionally induces  prolonged  vomitiivg.  the  effects  of  this  agent  iq)on  the 
bronchial  mucous  membrane  may  be  dangerous.  They  ])resent  them- 
selves clinically  in  the  well-known  evidences  of  irritation,  such  as 
bronchitis  and  broncho-pneumonia.  Whether  ether  is  employed  by 
rectum,  intravenously,  or  by  inhalation,  it  induces  an  active  and  imme- 
diate secretion  of  mucus.  If  the  nuicus  collects  in  the  air  passages 
and  is  not  cared  for  by  lowering  the  head  and  clearing  out  the  pharynx 
with  gauze  the  patient  is  in  danger  of  choking  or  of  inspiring  it.  In 
addition,  in  long  continued  anesthesia,  the  irritation  of  the  mucous 
membrane  may  lead  to  inflammation,  out  of  which  ether  pneumonia 
may  develop. 


12  ANESTHESIA 

SUDDEN  DEATH  DURING  ANESTHESIA 

Death  through  syncope  after  the  first  whiffs  of  chloroform  vapor 
occurs  quite  infrequently;  with  ether  it  is  rare.  Death  during  the 
course  of  the  anesthesia  may  develop  with  the  employment  of  ether 
as  well  as  with  chloroform,  and  Iiere  also  chloroform  exhibits  itself  as 
the  more  dangerous  agent,  on  account  of  its  great  toxicity,  if  reck- 
lessly applied. 

This  form  of  anesthetic  death  with  chloroform  may  be  avoided  prac- 
tically without  exception  if  the  anesthetist  notices  in  time  the  warning 
signals  which  precede  every  danger,  and  immediately  removes  the 
mask  and  starts  methods  of  resuscitation.  Thus  chloroform  death 
during  the  course  of  anesthesia  is  often  to  be  ascribed  not  to  the 
toxicity  of  the  agent  alone,  but  to  the  ignorance  or  inattention  of  the 
anesthetist  as  an  accessory.  Death  during  the  com-se  of  etlierization 
is  less  frequent,  but  it  may  happen  if  a  deep  narcosis  with  inordinately 
large  quantities  of  ether  is  continued  for  a  long  time,  with  a  closed  or 
semi-closed  inhaler.  This  danger  is  reduced  to  a  minimimi  if  ether  is 
employed  judicially,  by  the  drop  method.  As  regards  the  dangers 
which  develop  after  the  end  of  the  anesthesia,  chloroform  has  some 
advantage  over  ether. 

SEQUELAE  OF  CHLOROFORM  AND  ETHER 

Patients  with  sound  heart  muscle,  particularly  young  persons,  stand 
chloroform  well,  but  it  exercises  a  dangerous  and  sometimes  fatal 
effect  upon  degenerated  and  insufficient  heart  nniscle.  This  explains 
the  not  infrequent  cases  of  death  in  the  days  following  the  operation. 
Cardiac  paralysis  may  however  occur  in  certain  cases  after  ether  anes- 
thesia, even  if  limited  quantities  are  used,  death  being  due  to  nothing 
but  atonicity  of  the  heart  nmscle. 

Other  late  results  of  chloroform,  such  as  vomiting,  headache  and 
psychic  distiu'bances  are  observed  also  after  ether.  The  serious 
danger  with  ether  lies  in  its  injurious  effect  upon  the  bronchi  and  the 
alveoli  of  the  lungs.  Not  only  is  post-operative  broncho-pneumonia 
in  the  first  days  after  ether  anesthesia  more  frequent  than  when  chloro- 
form is  employed,  but  the  type  of  inflammation  is  more  severe.  It 
involves  larger  areas  of  the  limg,  and  is  more  difficult  to  treat.  This  is 
the  case  even  when  the  ether  is  chemically  pure,  and  is  not  given  in 
great  concentration.  Post-anesthetic  pneumonia  may  also  be  caused 
by  emboli,  which  are  set  free  from  thrombi  in  the  veins,  and  carried 
by  the  general  circulation  to  the  lungs.     In  this  regard  also  ether  is 


CHLOROFORM  AND  ETHER  13 

the  more  dangerous  agent,  because  it  decreases  the  coaguhibility  of 
the  blood.  Thrombosis  of  the  extremities,  apoplexy,  and  hematin-iu 
arc,  therefore,  more  frequently  observed  after  ether  than  after  chloro- 
form anesthesia.  With  chloroform,  after  recovery  from  the  anesthetic 
the  greatest  danger  is  over,  while  with  ether  a  certain  danger  of  com- 
plications persists  for  several  days.  IVIoreover,  with  chloroform  anes- 
thesia can  always  be  induced  i!i  patients  who  go  under  ether  with 
dilliculty,  and  only  by  the  use  of  large  and  harmful  quantities. 

SELECTION  Ol-  THE  AXES'J'HETIC 

The  choice  of  anesthetic  will  depend  on  the  result  of  the  physical 
examination.  Patients  with  uncompensated  lieart  lesions,  such  as 
edema,  cyanosis,  coronary  sclerosis  and  cardiac  dilatation  should  never 
receive  chloroform,  particidarly  when  the  insufficiency  is  the  result  of 
myocarditis.  Also  arythmia  of  the  pulse  demands  ether.  Degen- 
erated and  weak  heart  nuiscle  cannot  stand  the  toxic  action  of  chloro- 
form, and  the  patient  who  survives  the  operation  may  go  to  pieces 
within  a  few  days  after  the  anesthetic  with  syni])toms  of  progressing 
cardiac  weakness.  But  it  must  be  admitted  also  that  a  heart  with 
degenerated  muscle  fibre  usually  does  not  stand  ether  well.  Nor 
should  chloroform  be  employed  in  fresh  cases  of  endocarditis;  but  in 
compensated  heart  lesions,  on  the  other  hand,  it  may  be  used  without 
hesitation  in  limited  quantities.  On  account  of  its  paralyzing  effect 
upon  the  heart,  chloroform  is  dangerous  in  all  patients  with  arterio- 
sclerosis; to  be  sure  these  patients  also  stand  ether  poorly  and  throm- 
bosis and  brain  hemorrhage  are  particularly  to  be  feared  as  compli- 
cations. Also  the  employment  of  chloroform  in  diabetes  is  to  be 
avoided.  But  the  use  of  ether  may  not  prevent  the  onset  of  an  attack 
of  diabetic  coma.  Chloroform  is  also  contra-indicated  in  status 
thymicus  and  lymphatieus  as  well  as  in  Basedow's  and  iVddison's  dis- 
ease, and  in  advanced  tuberculosis  with  amyloid  degeneration. 

On  the  other  hand  where  a  tendenc}'^  to  pneumonia  and  to  catarrhal 
manifestations  of  the  organs  of  respiration  exists,  ether  should  be 
avoided  as  an  anesthetic,  because  the  particles  of  ether  circulating 
through  the  body,  whether  inhaled  as  vapor  or  introduced  in  any  other 
way,  for  instance  by  rectum  or  intravenously,  irritate  the  mucous 
membrane  of  lungs  and  bronchi  and  set  up  a  considerable  secretion. 
Through  aspiration  of  mucus  and  saliva  and  as  a  result  of  the  direct 
toxic  effect  of  ether  u])on  the  alveolar  and  bronchial  epithelium,  ])ost- 
anesthetic  pneumonia  is  apt  to  occur  in  the  presence  of  existing  disease 


14  ANESTHESIA 

of  the  respiratory  track.  In  operations  upon  the  chest  and  the 
abdomen  it  is  important  that  the  patient  should  be  reheved  of  the 
strain  of  coughing,  and  particularly  of  all  changes  of  position  which 
may  be  necessary  for  better  ventilation  of  the  lungs.  Ether  is  not 
toxic  to  the  heart,  but  the  heart  functions  do  not  always  suffice  to 
overcome  a  pneumonia  which  is  caused  by  ether,  while  the  small 
amount  of  chloroform  which  is  necessary  for  these  cases  hardly  has 
any  effect  upon  the  heart. 

Alcoholics  and  patients  with  kidney  disease  stand  ether  more  poorly 
than  they  do  chloroform.  On  the  other  liand  ether  may  be  admin- 
istered by  an  unskilled  person  if  necessary,  in  whose  hands  chloroform 
anesthesia  would  be  attended  bj^  very  grave  danger.  Frequent  repeti- 
tion of  either  chloroform  or  ether  anesthesia  sliould  be  avoided, 
especially  in  the  young  and  the  aged,  on  account  of  the  cumulative 
effect  of  their  destructive  action  on  liver  and  kidneys. 

SCOPOLAMIN   AND   MORPHINE   AS   A   PRELIMINARY   TO   ANESTHESIA 

Half  or  three-quarters  of  an  hour  before  the  anesthesia  is  started 
the  patient  may  be  given  a  subcutaneous  injection  of  1/120  grain  of 
scopolamin  hydrobromate  together  with  1/6  grain  of  morphine  hydro- 
chlorate.  This  injection  is  given  once  only  and  is  not  repeated. 
Scopolamin-morphine  exerts  a  quieting  influence  upon  the  mental 
state,  and  upon  humanitarian  grounds  it  maj'  be  used  in  all  cases 
where  no  contra-indication  exists.  The  pertin-bation  and  anxiety 
which  precede  the  operation  give  way  to  a  peaceful  imconsciousness 
and  quiet  sleep.  The  patient  loses  in  large  measiu'e  all  memory  of  the 
moments  preceding  the  operation,  he  remembers  little  or  nothing  of 
the  transportation  to  the  operating  room,  and  often  on  awakening 
several  hours  after  the  completion  of  the  ojjeration,  is  astonished  that 
the  operation  is  already  over. 

As  regards  the  anesthesia,  the  use  of  these  agents  possesses  direct 
advantages,  for  the  anesthesia  can  be  induced  with  a  smaller  quantity 
of  ether,  and  frequently  no  trace  of  the  stage  of  excitement  appears; 
moreover  the  anesthesia  is  less  likely  to  be  disturbed  by  spasm  of  the 
muscles  or  vomiting.  Often  for  considerable  intervals,  for  instance 
while  intestines  are  being  anastomosed,  the  anesthetic  may  be  prac- 
tically withheld  without  the  patient  awakening  or  becoming  unquiet. 
The  cumidative  toxic  effect  of  the  anesthetic  is  unquestiona])ly  de- 
creased, because  when  this  combination  is  used  a  smaller  quantity  of 
the  anesthetic  is  required. 


SCOPOLAMIXE-MOUrHIXE  15 

Weak  or  anemic  women  and  youthful  patients  may  be  given  an 
injection  of  1  l.)0  yrain  of  scopolainin.  Alcoholics,  on  the  other  hand, 
require  a  larij^er  close  in  order  to  <)et  the  same  result.  ^lore  tlian 
1  80  grain  of  scopolamin  should  never  be  given.  On  account  of  its 
toxic  properties,  ciiildren  under  the  age  of  fifteen  should  never  be 
given  scopolainin. 

Among  other  j)r<)perties  of  the  scopolamin-morphinc  injection  must 
be  reckoned  the  fa\()ral)le  effect  upon  llie  setjuela'  of  tlie  anesthesia. 
Post-anesthetic  lung  affections  and  particularly  vomiting  are  consid- 
erably less  frequent  after  the  operation  M'hen  it  is  employed.  This 
is  explained  by  the  effect  of  the  scopolamin  in  drying  the  mucous 
membranes. 

One  drawback  of  scopolamin  consists  in  the  fact  that  it  is  a  jaoison 
which  is  not  readily  excreted  from  the  body  after  injection.  Its 
toxic  effect  is  recognizable  particularly  on  the  respiration  and  the 
blood  vessels.  Although  fatal  results  are  practically  never  heard  of 
from  the  small  doses  described,  disturbing  concomitants  may  occur  in 
the  way  of  superficial  breathing,  collapse,  and  even  a  certain  grade 
of  cyanosis.  The  loss  of  the  vessel  tone  and  the  paralysis  of  the 
arterioles  and  ca])illaries  as  the  result  of  the  action  of  scopolamin  cause 
diffuse  bleeding,  and  the  wound  of  a  head  or  face  operation,  for 
instance,  may  bleed  like  a  squeezed  sponge  without  it  being  possible 
to  seize  the  small  vessels  and  stop  the  bleeding  by  any  other  means 
than  pressure. 

On  account  of  the  cyanosis,  the  danger  of  collapse  and  the  tendency 
to  sujjcrlicial  breathing  it  is  advisable  in  the  second  stage  of  cranial 
operations  to  avoid  scopolamin,  for  patients  with  brain  tumors  are 
likely  to  suffer  from  disturbances  of  resi)iration  as  a  result  of  pres- 
sure. Not  infre(]uently  tiiis  goes  so  far  as  to  cause  a  complete  cessation 
of  respiration,  and  in  this  regard  the  scoj)olamin  simply  augments  the 
action  of  the  brain  tumor.  Attempts  to  overcome  this  paralysis  by 
the  aid  of  ordinary  resuscitative  methods  or  with  antidotes  are  without 
result,  for  scopolanu'n  is  not  readily  excreted  and  its  effect  lasts  for 
several  hours.  Its  use  shoulil  be  avoided  particularly  in  operations 
upon  the  nose,  mouth,  pharynx  and  larynx,  for  after  such  procedures 
it  is  necessary  that  the  patient  awake  from  the  anesthetic  as  soon  as 
possible,  in  order  to  cough  up  any  blood  which  has  been  aspirated, 
or  has  flowed  down  into  the  bronchi  unnoticed. 

The  substitution  of  pantopon  for  the  morphine,  |)articularly  in  skull 
operations,  undoubtedly  results  in  a  decrease  in  the  venous  hyperemia 


16  ANESTHESIA 

of  the  head  during  the  anesthesia.  Also  the  deep  sleep  of  the  patient 
at  the  end  of  the  operation  is  not  so  prolonged  with  scopolaniin- 
pantopon  as  with  scopolaniin-morphine,  and  the  patient  may  be  imme- 
diately awakened  out  of  his  slumber.  In  the  same  waj'  the  patient 
seems  to  suffer  less  from  inactivity  of  the  bowels  in  the  first  few  days 
after  the  operation  if  pantopon  is  used.  But  on  the  other  hand  on 
account  of  the  collapse  which  has  been  observed  with  scopolamin- 
pantopon  immediately  at  the  beginning  of  the  anesthesia  in  celio- 
tomies, it  is  wise  to  continue  the  use  of  morphine  in  all  abdominal 
operations. 

Either  combination  should  never  be  used  except  in  the  hands  of  a 
skilled  anesthetist.  Its  contra-indications  as  stated  by  Herb*  are  as 
follows:  In  patients  in  whom  the  respiratory  centre  is  depressed  or 
likely  to  become  depressed  through  operative  procedures;  obstructive 
dyspnoea  due  to  growth  within  or  without  the  trachea,  causing  pres- 
sure, or  exophthalmic  goitre;  in  operations  about  mouth  or  throat; 
in  the  case  of  debilitated  or  cachetic  persons  or  those  suffermg  with 
continued  sepsis ;  in  patients  presenting  any  degree  of  stupor  or  those 
susceptible  to  morphine;  as  well  as  in  children  and  the  elderly. 

TECHNIQUE  OF  CHLOROFORM  ANESTHESIA 

In  administering  chloroform  particidar  care  must  be  taken  that  too 
large  a  quantity  is  not  poured  upon  the  mask  at  one  time,  and  more- 
over, since  concentration  of  the  poison  increases  its  danger  to  the 
heart,  a  sufficient  quantity  of  air  should  always  accompany  the  vapor. 

The  mask  should  never  be  saturated  with  chloroform  and  then 
applied  to  the  face,  but  it  should  at  first  be  held  dry  some  little  dis- 
tance from  the  face  until  the  patient,  after  a  few  inspirations  of  air, 
has  become  accustomed  to  it.  Then  the  narcosis  is  begun  with  a  few 
drops  of  chloroform,  which  are  dropped  upon  the  mask  at  intervals. 
In  the  beginning  the  patient  thus  receives  chloroform  vapor  mixed 
with  considerable  air,  and  with  a  careful  administration  suff'ocation, 
nausea  and  anxiety  do  not  appear.  After  a  short  period  the  frequency 
of  the  drop  is  increased  and  at  the  same  time  the  mask  is  gradually 
approached  to  the  face. 

After  the  first  few  inspirations,  the  danger  of  syncope  beizig  over, 
the  depth  of  the  anesthesia  is  increased,  the  respiration,  pulse  and 
pupillary  reaction  and  the  color  of  the  face  being  carefully  noted. 
Loss  of  the  pupillary  reaction  denotes  the  limit  which  the  anesthesia 

*Jour.  Amer.  Med.  Ass.,  1913,  Ixi,  834 


CHLOROFORM  ANESTHESIA  17 

should  be  allowed  to  reach;  for  this  represents  a  paralysis  of  a  portion 
of  the  brain  which  is  in  close  relation  to  the  vagus  centre  and  to  the 
centres  which  exercise  an  effect  upon  respiration  and  cardiac  activity. 
Even  slight  disturbances  of  respiration  sliuuld  induce  tiic  anesthetist 
to  interrupt  the  application  of  chloroform. 

Disturbances  of  respiration  may  be  caused  mechanically  or  as  the 
result  of  paralysis  of  the  centre  of  respiration.  Opening  the  mouth  by 
means  of  a  mouth  gag  is  not  sufficient  to  clear  the  entrance  to  the 
larynx  because  not  only  the  epiglottis  but  also  the  tongue  wliich  has 
dropped  back  against  the  posterior  wall  of  the  larynx  shuts  off  the 
passage-way.  The  tongue  must  be  seized  by  tongue  forceps,  if  the 
air  way  is  obstructed,  and  pulled  as  far  as  possible  out  of  the  mouth. 
Paralysis  of  the  centre  of  respiration  in  chloroform  anesthesia  is  rare, 
but  with  ether  it  is  less  so.  We  have  frequently  seen  cessation  of 
respiration  during  operation  upon  brain  tumor,  but  there  is  no  ques- 
tion in  these  cases  but  that  intracranial  pressure  is  as  much  to  blame 
as  the  anesthetic,  for  respiration  has  been  seen  to  stop  in  tumors  in 
the  cerebellum  even  after  the  chloroform  had  been  discontinued  for 
some  while,  and  patients  have  died  of  respiratory  failure  imder  local 
anesthesia,  while  the  heart  has  been  kept  going  by  artificial  means  for 
several  hours. 

A\'hilc  paralysis  of  respiration  may  be  largely  overcome  by  the  insti- 
tution of  artificial  respiration,  the  disturbances  of  circulation  during 
chloroform  anesthesia  are  fraught  with  graver  danger  to  the  patient. 
Toxic  paralysis  of  the  heart  muscle  announces  itself  by  a  gradual  loss 
in  its  power.  The  blood  becomes  dark  in  color,  the  face  is  cyanotic 
or  white  and  the  pulse  becomes  more  frecpient,  as  a  rule,  smaller  in 
volume,  and  finally  quite  thready.  Cardiac  paralysis  occurs  at  the 
beginning  of  the  anesthesia,  as  well  as  with  an  anesthesia  of  long  diu'a- 
tion,  for  which  large  quantities  of  ether  or  cliloroform  are  necessary. 
Naturally  cardiac  difficulties  are  more  likely  to  arise  during  opera- 
tions where  there  has  been  a  considerable  loss  of  blood,  or  reflex  dis- 
turbances through  irritation  of  the  peritoneum  and  through  changes 
in  pressure  within  the  thorax  and  abdomen.  Tlie  careful  and  experi- 
enced anesthetist  notices  the  gradually  increasing  weakness  of  the 
heart  by  the  quality  of  the  pulse  and  the  color  of  the  face.  Since  it  never 
develops  suddcidy  but  always  announces  itself  early  by  these  symp- 
toms, it  can  be  met  with  cardiac  stimulants,  such  as  stiychnine, 
camplior,  caffeine,  infusion  of  salt  solution,  and  lowering  of  the  head. 
We  should  make  early  and  prophylactic  use  of  the  rapidly  acting 


18  ANESTHESIA 

camphor,  because  when  injected  subciitaneoiisly,  by  its  stimulant 
action  upon  the  vasomotor  system  it  readily  overcomes  the  early  signs 
of  cardiac  weakness. 

If  the  heart  has  stopped  beating  all  attempts  by  means  of  injection 
of  drugs  are  useless,  because  they  remain  at  the  site  of  injection 
and  on  account  of  the  failing  circulation  reach  neither  brain  nor  heart. 
In  such  case  attempt  must  be  made  to  stimulate  the  heart  to  action 
by  means  of  indirect  or  direct  massage.  Short  powerful  thrusts  must 
be  made  ^\itli  the  right  hand  lying  upon  the  chest  wall  in  the  region 
of  the  heart  at  the  rate  of  at  least  60  times  a  minute.  The  heart  is 
shaken  through  the  chest  wall  and  is  thereby  stimulated  to  contraction. 
This  procedure  usually  succeeds.  It  must  be  accompanied  liy  artificial 
respiration  in  order  to  overcome  the  supersaturation  of  the  blood  with 
carbon  dioxide.  As  soon  as  the  heart  begins  to  beat  again,  one  should 
inject  stimulants  in  order  to  support  its  activity.  If  the  abdomen  is 
open  the  hand  can  be  pushed  through  the  celiotomy  wound  and  the 
heart  can  be  directly  compressed  and  massaged  against  the  chest  wall 
through  the  diaphragm.  As  a  last  resort  direct  massage  of  the  heart 
may  be  instituted  after  resection  of  the  fifth  costal  cartilage  on  the 
left  side  and  opening  of  the  pericardium.  Two  fingers  are  shoved 
under  the  base  of  the  heart  and  the  heart  rhythmically  compressed 
against  the  chest  wall,  or  carefully  kneaded. 

Care  should  be  taken  that  chloroform  is  kept  in  a  cool  place  and 
away  from  light.  A  fresh  container  should  be  opened  for  each  opera- 
tion, and  when  the  operation  is  over  the  remainder  in  the  bottle  should 
be  thrown  away,  and  not  used  for  anesthesia. 

ADMINISTRATION  OF  ETHER 

The  conduct  of  ether  anesthesia  requires  less  care  in  the  observation 
of  the  cardiac  activity.  Ordinarily  the  pulse  remains  full  and  strong, 
because  ether  is  a  stimulant  to  the  heart  nuiscle,  while  chloroform  is 
depressant.  For  this  reason,  in  patients  who  are  sick  ether  is  the 
anesthetic  of  choice.  But  after  a  prolonged  administration  ether 
begins  to  show  a  toxic  action  upon  the  heart  muscle,  and  the  same 
symptoms  of  cardiac  depression  appear  as  with  the  employment  of 
chloi-oform. 

On  the  other  hand  ether  demands  a  more  careful  observation  of  the 
respiration,  and  the  respiratory  track.  If  the  lireathing  remains 
strong,  the  inspired  air  being  mixed  with  the  richly  secreted  mucus 
makes  a  churning,  gurgling  noise.     ^^Mlile  this  sonorous  respiration 


ADMINISTRATION  OF  ETHER  19 

during  ether  anesthesia  is  to  be  taken  as  a  sign  that  there  is  no  obstruc- 
tion, at  the  same  time  there  is  a  certain  amount  of  chinger  connected 
with  it.  So  long  as  these  secretions  are  hmited  to  the  mouth  and  the 
pharynx  they  are  harmless,  because  they  may  be  removed  through 
lowering  the  head  and  M^iping  out  the  pliarynx  down  to  tiie  epiglottis. 
But  the  secretion  is  more  dangerous  in  the  bronchi  and  bronchioles 
of  the  lung,  from  Avhicli  they  are  not  removed  until  the  end  of  anes- 
thesia. They  remain  there  until  the  patient  coughs  them  out.  In  this 
lies  the  greatest  danger  of  ether  anesthesia,  for  during  deep  anestliesia 
mucus  and  other  material  from  the  nose,  mouth  and  pharynx  run  down 
into  the  bronchi  or  are  inspired,  and  can  only  be  removed  through 
coughing  and  retching.  For  this  reason  preliminary  cleansing  of  the 
mouth  is  particularly  advisable.  Many  surgeons  limit  the  otherwise 
copious  secretion  by  an  injection  of  one  one-hundredth  grain  of 
atroj)in  and  one-sixth  of  morphine  before  starting  anesthesia. 

"While  in  young  and  strong  patients  this  nuicus  seldom  forms  a 
serious  obstruction  to  respiration,  nevertheless  in  weaker  patients,  and 
particularly  those  with  poor  hearts,  it  may  threaten,  during  the  course 
of  anesthesia,  to  lead  to  suffocation.  This  is  brought  about  by  the  fact 
that  the  tenacious  mucus  sticks  together  in  a  mass  and  in  that  way  a 
narrowing  of  the  respiratory  passage  results,  which  if  the  patient  has 
not  the  strength  to  overcome,  acts  as  an  obstruction  to  breathing. 
The  patient  then  does  not  become  cyanotic,  as  would  occur  if  the 
heart  were  affected,  but  pale,  and  the  heart  weakens  simultaneously 
with  res])iration.  The  respiration  and  cardiac  acti\  ity  may  be  restored 
if  at  the  right  time  the  tongue  is  pulled  out  and  the  pharynx  wijjcd 
clean. 

Otherwise  ether  anesthesia  is  carried  on  just  as  chloroform.  The 
ether  is  poured  out  of  a  drop  bottle,  at  first  slowly,  and  then  faster, 
upon  a  mask  which  carries  12  or  10  layers  of  thick  gauze,  and  the 
drops  are  increased  rapidly  until  the  stage  of  excitement  is  passed. 
Then  when  the  patient  sleeps  quietly,  as  may  be  inferred  from  the 
sonorous  respiration,  the  quantity  is  again  decreased.  In  alcoholics 
the  excitation  is  a])t  to  be  particularly  severe,  and  it  is  sometimes 
difhcidt  to  get  them  under  with  ether  alone.  Instead  of  pouring  on 
excessive  (juantities  of  ether,  it  may  be  advisable  to  start  the  anesthesia 
with  clilDroform  oi-  ancsthol. 

Experiments  with  the  Council  anesthetometer*  have  shown  that 
the  inspired  air  must  contain  30  per  cent,  of  ether  vapor  by  weight  to 

*Boothby,  Jour.  Amer.  Med.  Ass.,  1013,  Ixi,.S30. 


20  ANESTHESIA 

saturate  the  blood  sufficiently  for  the  induction  of  full  surgical  anes- 
thesia, and  that  after  relaxation  a  15  per  cent,  vapor  is  strong  enough 
to  prevent  diffusion  outward  from  the  tissues  and  to  maintain  the 
requisite  ether  content  of  the  blood.  In  alcoholics,  ether  apparently 
exerts  greater  excitatory  power  on  the  respiratory  centre  than  in  non- 
alcoholics.  Naturally  a  greater  quantity  of  ether  is  required  to  bring 
this  larger  volume  of  respired  air  up  to  the  30  per  cent,  requisite  for 
induction.  But  an  expert  anesthetist  using  gauze  and  the  drop 
method  will  induce  an  anesthesia  rapidly  and  smoothly  without  caus- 
ing excitement  or  suffocation  and  the  deeper  j-espiration  which  results. 
The  percentage  of  the  ether  vapor  may  be  raised  by  holding  the  hands 
in  turn  on  the  side  of  the  mask,  so  as  to  increase  the  vaporization  by 
their  warmth. 

ETHER  IN  MINOR  SURGERY 

In  order  to  carry  out  minor  j^rocedures,  ether  may  be  employed  in 
any  one  of  a  number  of  ways.  The  best  knoAvn  is  the  suffocation 
method,  with  a  closed  mask.  A  Blake  cone  with  a  close-fitting  face- 
piece  is  stuffed  tightly  with  gauze,  or  the  outside  of  a  Juillard  mask  is 
covered  with  an  impermeable  material,  and  inside  is  placed  a  tight 
wad  of  gauze  the  size  of  the  fist.  Upon  the  gauze  about  2  ounces  of 
ether  is  poured,  the  excess  which  is  not  absorbed  by  the  material  is 
shaken  out,  and  the  cone  filled  with  ether  vapor  is  set  upon  the  face. 
At  first  the  patient  feels  as  if  he  must  suffocate,  particularly  when  a 
towel  is  wrapped  about  the  edge  of  the  cone  to  aid  in  preventing  the 
access  of  air.  Immediately  there  results  a  violent  struggling  and  a 
sudden  powerfid  excitation,  wliich  is  increased  as  the  irritation  of  the 
ether  upon  the  mucous  membranes  causes  a  reflex  closure  of  the 
glottis.  In  addition  to  the  ether  we  then  have  the  narcotic  effect  of 
the  supersaturation  of  the  carbon  dioxid  in  the  blood.  This  condition, 
which  is  dangerous  to  the  heart  and  respiration,  disappears  as  soon  as 
the  cone  is  lifted  to  allow  a  single  inspiration  of  fresh  air.  The  spasm 
of  the  glottis  and  sense  of  suffocation  disappear,  and  inspiration  of 
the  ether  vapor  follows  without  further  trouble  until  deep  anesthesia 
is  induced. 

For  the  setting  of  fractures  and  the  reduction  of  dislocations,  for 
small  amputations,  and  the  incision  of  abscesses,  this  method  works 
rapidly  and  gives  a  satisfactory  anesthesia.  It  has  been  completely 
discarded,  however,  by  most  surgeons  on  account  of  the  danger  to  the 
heart,  from  the  sudden  crowding  of  the  ether,  and  the  suffocation. 


PRIMARY  ETHERIZATION  21 

Naturally,  it  should  never  be  used  iu  old  or  weak  patients  or  when 
the  heart  or  the  vessels  are  diseased. 

A  less  dangerous  modification  of  this  method  consists  in  pouring 
about  an  ounce  of  ether  upon  a  cone  and  gradually  approaching  it 
to  the  face,  until  the  irritative  symptoms  and  the  sense  of  suffocation 
have  been  overcome,  when  a  large  quantity  of  ether  is  poured  on  and 
the  cone  is  placed  u])on  the  face.  ^lore  ether  is  poured  into  the  cone 
from  time  to  time  as  recjuired.  This  method  takes  longer  than  the 
suffocation  method,  and  it  demands  a  larger  amount  of  ether,  because 
it  is  diluted  with  air.  Eut  on  account  of  the  inspiration  of  concen- 
trated ether  vapor  for  a  considerable  time  it  is  not  harmless  to  the 
lungs  and  it  in  no  way  possesses  the  advantages  of  the  drop  method. 

The  method  best  suited  for  short  minor  procedures  depends  upon 
the  employment  of  the  analgesia  which  accompanies  the  stage  of 
excitation  at  the  beginning  of  anesthesia.  This  is  similar  to  the 
methods  of  pre-anesthesia  days,  when  the  sensibility  was  deadened  by 
alcohol  and  other  exciting  agents.  In  the  ether  "rausch,"  so  called, 
the  patient  maintains  consciousness,  hears  and  answers  questions, 
losing  oidy  the  sense  of  pain. 

The  conduct  of  a  primary  etherization  is  carried  on  according  to 
Sudck*  in  the  following  way:  A  mask  such  as  is  used  for  the  drop 
method  is  laid  ui)on  the  face  dry,  and  when  the  patient  has  become 
accustomed  to  its  presence  a  few  drops  of  ether  are  applied,  at  first 
at  long  intervals  and  then  more  rapidly.  There  is  no  unpleasant  sense 
of  suffocation  because  the  quantity  at  first  is  small  and  the  dilution  of 
the  vapor  with  air  is  great.  The  i)atient  may  be  directed  to  hold  the 
arm  up  in  the  air,  or  to  coimt  out  loud.  At  the  end  of  about  fifteen 
full  inspirations,  the  anesthesia  is  tried  by  a  needle  prick.  The  right 
moment  of  loss  of  sensibility  to  pain  is  reached  when  the  arm  sinks, 
the  counting  is  interrupted  or  the  prick  of  the  needle  no  longer  felt. 
This  primary  etherization  is  not  true  anesthesia,  for  during  its  course 
the  patient  can  answer  questions  and  may  talk  in  lively  fashion,  and 
sometimes  even  cries  out,  without  later,  at  the  end  of  the  operation, 
being  able  to  recall  anv  sensation  of  pain.  ITe  is  conscious,  however, 
of  the  noise  of  the  instruments;  he  hears,  sees,  and  is  physically  aware 
of  what  is  happening  to  him,  but  he  appreciates  no  painful  .sensation. 
There  is  no  danger  of  harmful  results  connected  with  this  foiin  of 
etherization;  the  patient  may  get  up  as  soon  as  the  o])eration  is  over. 

This  method  is  ajjplicable  j^articularly  for  the  removal  of  stitches, 

*Verhanci.  tier  d.  Ges.  f.  Cliir.,  1909,  p.  414. 


22  ANESTHESIA 

the  extraction  of  the  roots  of  teeth,  the  incision  of  furuncles  and  the 
evacuation  of  abscesses  and  similar  minor  but  painful  procedures. 
Since  reflex  activity  and  muscle  spasm  are  decreased  but  not  entirelv 
overcome,  the  application  of  this  method  to  more  extensive  operations, 
such  as  the  reduction  of  dislocations  and  the  setting  of  fractures,  is 
impracticable.  The  analgesia  is  at  its  height  at  the  beginning  of  the 
"rausch,"  but  it  disappears  rapidly  as  the  administration  is  continued. 

NITROUS  OXIDE    (gas) 

Nitrous  oxide  or  laughing  gas  has  been  very  generally  used  in 
America  for  minor  surgical  and  dental  work  since  its  introduction  in 
1844.  It  was  first  applied  to  major  surgery,  in  combination  with 
oxygen,  by  Andrews  of  Chicago,  in  1868.  Recently,  under  the  leader- 
ship of  Crile,  its  use  in  major  surgery  has  extended.  In  Europe 
nitrous  oxide  has  not  been  adopted  to  any  great  extent,  largely  be- 
cause the  gas  cannot  be  obtained  generally  at  a  reasonable  cost  and  in 
portable  form. 

For  minor  surgical  procedures  it  is  probably  the  most  effective 
agent  at  our  disposal.  It  should  not  be  given  to  the  very  yoimg,  or 
the  aged,  or  those  with  heart  or  lung  complications.  It  is  not  un- 
pleasant, there  is  no  troublesome  preliminary  stage  of  excitement, 
anesthesia  is  complete  after  10  or  12  full  inhalations,  and  recovery  is 
immediate,  without  after-effects. 

Naturally  its  use  must  ordinarily  be  limited  to  procedures  requiring 
not  more  than  a  minute  to  carry  out.  However,  with  an  experienced 
anesthetist,  watching  the  color  and  the  respiration,  the  patient  may  be 
kept  under  for  as  long  as  ten  minutes,  by  alternating  gas  and  air  as 
required.  It  is  not  particularly  good  for  setting  fractures,  on  account 
of  the  necessary  hurry,  the  spasm,  and  sometimes  the  involuntary 
movements  of  the  patient.  It  is  excellent  for  incision  of  abscesses, 
excision  of  carbuncles,  and  other  rapid  minor  jirocedures,  and  for 
painful  post-operative  dressings.  It  has  been  generally  applied  in 
polite  practice  for  some  years  as  an  agreeable  agent  for  the  induction 
of  anesthesia  as  a  preliminary  to  ether,  using  a  gas-ether  sequence 
apparatus,  such  as  that  of  Gwathmey  or  Bennett. 

The  anesthesia  under  nitrous  oxide  depends  upon  a  diminution  of 
the  oxygen  supply  to  the  brain,  as  part  of  a  general  pseudo-asphyxia- 
tion. Cyanosis  is  one  of  the  accompanying  phenomena.  The  zone 
of  harndess  anesthesia,  however,  is  narrowly  limited,  and  the  pressure 
of  the  gas  and  the  proportion  of  air  must  be  regulated  with  watchful 


NITROUS  OXIDE  23 

care.  "With  an  over-dose  the  cyanosis  increases,  the  resj^iration  be- 
comes stertorous  and  sometimes  crowing,  muscular  twitchings  appear, 
which  develop  into  clonic  contractions  and  possibly  a  general  con- 
vulsive seizure,  and  the  patient  if  neglected  dies.  Deaths  under  gas, 
however,  are  practically  unheard  of,  as  there  is  ample  warning,  and 
fresh  air  relieves  the  symptoms. 

Gas  can  be  purchased  in  containers  of  various  sizes  at  the  cost  of 
a  few  cents  per  anestliesia,  from  makers  throughout  the  country. 
Some  hospitals  make  their  own  gas,  and  pipe  it  under  low  pressure 
to  the  operating  rooms.  The  apparatus  for  its  administration  should 
be  the  simplest  j)ossible.  It  consists  of  a  yoke,  to  make  connection 
with  the  tank,  which  has  a  handle  to  control  the  flow.  A  large  size 
rubber  tube  goes  from  the  yoke  to  a  rubber  balloon,  holding  when 
inflated  about  two  gallons.  A  short  tube,  about  one  inch  in  diameter, 
runs  to  the  face  piece.  This  should  be  made  with  an  inflated  rubber 
pad  to  fit  the  hollows  of  the  face,  or  a  rubber  sleeve,  to  strap  behind 
the  head.  It  should  entirely  exclude  all  outside  air.  There  should  be  a 
large  expiratory  valve,  which  may  be  closed,  and  a  valve  on  the  intake, 
Avhich  should  allow  of  all  gradations  from  pure  air  to  pure  gas,  and 
for  rebreathing  into  the  bag. 

For  mnjor  operative  rcnrk  oxygen  must  be  su])plied  Avith  the  gas, 
in  varying  projjortions.  The  best  a])])aratus,  of  which  the  Boothby 
machine  is  an  example,  are  equipped  with  a  device  for  turning  ether 
vapor  into  the  circuit  also  as  needed.  Crile  has  used  gas-oxygen  in 
over  4.000  general  svirgical  cases,  and  he  states  that  it  reduces  mor- 
tality  and  lessens  suffering.  Shock  occui-s  less  than  one-half  as  fre- 
quently as  with  ether,  and  "apparently  the  worse  the  risk  the  better 
it  acts."  It  is  not  unpleasant  to  take,  the  nausea  is  trifling,  and  com- 
plications rare.  The  cellular  degeneration  in  brain,  kidney  and  liver 
is  j)robably  much  less  than  after  the  use  of  any  other  anesthetic  agent. 
The  post-operative  impairment  of  vitality  is  distinctly  less,  and  if 
occasion  arises,  the  patient  shows  no  hesitation  about  returning  for 
another  operation. 

On  the  other  hand  it  nnist  be  said  that  the  apparatus  for  its  admin- 
istration is  costly  and  com])licated,  and  that  the  gas  and  oxygen  are 
items  of  IK)  inconsiderable  expense,  standing  the  occasional  adnn'nis- 
trator  in  private  ])ractice  $1.5  or  more  for  a  long  anesthetization.  No 
one  but  a  skilled  person  should  be  trusted  with  the  method,  and  he 
must  give  his  undivided  and  intelligent  attention  to  the  patient.  A 
j)reliminary  injection  of  scopolumin-morphine  is  usually  considered 


2-i  ANESTHESIA 

necessary.  On  account  of  the  persistence  of  muscle  spasm  ether  vapor 
must  frequently  be  employed,  or  novocain  or  some  other  local  anes- 
thetic injected  into  the  muscles  along  the  line  of  incision.  The  unac- 
customed surgeon  is  hampered  and  the  operating  time  is  considerablv 
lengthened  by  the  increased  venous  hemorrhage,  the  spasm,  and  the 
time  necessary  for  the  local  injections  to  take  effect. 

At  the  present  stage  of  its  development  the  method  is  distinctly 
one  for  hospitals  where  particular  interest  can  be  given,  trained 
anesthetists  developed,  and  the  surgeon  re-educated.  According  to 
Crile,  the  results  well  repay  the  effort. 

ETHYL   CHLORIDE 

To  obtain  in  the  office  or  out-patient  clinic  a  reasonably  safe 
ephemeral  anesthesia,  ethyl  chloride,  such  as  maj^  be  obtained  in  glass 
tubes  with  a  spring  stopper,  has  been  used  for  some  years.  The  best 
mask  is  an  ordinary  chloroform  mask  covered  with  gauze,  but  over  the 
gauze  a  piece  of  rubber  tissue  should  be  fitted,  with  a  hole  at  the  middle 
the  size  of  a  five  cent  piece.  Upon  this  the  spray  of  ethyl  chloride 
is  played;  tlie  warmth  of  the  hand  suffices  after  the  stopper  is  open 
to  vaporize  the  ethyl  chloride  and  drive  it  out  under  pressure  through 
the  capillary  canal  in  the  neck  of  the  tulie.  In  children  the  spray  is 
unnecessary,  and  the  ethyl  chloride  may  be  given  in  smaller  quantity 
drop  by  drop,  by  partially  opening  the  stopper.  One  hundred  drops 
or  a  spray  which  is  played  for  about  twenty  seconds  induces  a  com- 
plete loss  of  sensibility  to  pain.  Patients  may  be  Ij'ing  do^vn  or  in  a 
sitting  posture.  They  are  not  unconscious,  but  ca^^  open  or  shut  the 
mouth  and  may  grip  the  arms  of  the  chair.  A  short  period  of  reaction 
usually  follows,  during  which  the  patient  laughs  and  talks  unrestrain- 
edly or  acts  as  if  partially  intoxicated.  Ktliyl  chloride  is  economical 
because  the  tube  alloAvs  its  being  used  in  small  quantities.  Ethyl 
chloride  should  not  be  used  for  complete  anesthesia  on  account  of  its 
dangerous  possibilities. 

SPINAL  ANESTHESIA 

In  old  persons  with  degenerated  heart  muscle,  arteriosclerosis,  ajid 
chronic  bronchitis,  we  have  at  times  in  operations  in  the  lower  abdom- 
inal region  or  on  the  lower  extremities  made  use  of  spinal  anesthesia 
after  the  method  of  Bier.  At  first  we  used  stovain,  but  more  recently 
we  have  employed  the  older  and  less  dangerous  drug,  tropacocain 
hydrochlorate.    It  is  less  powerful  as  an  anesthetic,  but  it  is  easilj^  sol- 


SPINAL  ANESTHESIA  25 

uble  in  water  and  may  be  freshly  sterilized  before  use.  Many  surgeons 
use  the  drug  in  powder  form,  placing  it  in  the  barrel  of  the  syringe 
and  allowing  it  to  dissolve  in  the  aspirated  meningeal  fluid.  A  dose 
of  9  10  grain  in  a  half  dram  (2  c.c.)  of  the  fluid  serves  to  induce 
anesthesia  in  five  to  ten  minutes  from  the  navel  downwards.  The 
tropacocain  may  be  bought  dissolved  ready  for  use  in  glass  ampullae. 
Xovocain  has  no  advantage  over  tropacocain  even  when  its  effects  are 
heightened  by  the  addition  of  adrenalin. 

The  successful  employment  of  spinal  anesthesia  depends  chiefly 
upon  the  technique  of  injection.  If  when  the  needle  has  penetrated 
into  the  dural  canal  and  the  anesthetic  has  been  injected,  the  expected 
effect  does  not  appear,  the  fault  lies  either  in  incomi)lete  solution  of 
the  powdered  drug  in  the  spinal  fluid,  or  its  mixture  with  blood,  a 
leaking  out  of  the  fluid  through  the  site  of  injection,  or  in  the  posture 
of  the  jDatient.  With  skilled  technique  these  difficulties  diminish  so 
that  with  surgeons  practised  in  the  method  bad  sequelte  and  death 
rarely  occur.  In  our  own  limited  expei'ience  we  have  seen  neither 
death  nor  persistent  disturbances  of  any  sort,  but  at  the  beginning  we 
had  several  failures. 

The  harmful  results  depend  upon  the  toxic  effects  of  the  drug  upon 
the  nerve  tissues.  Particularly  commonly  observed  are  fainting  and 
collapse,  nausea  and  vomiting,  and  ])artieularly  the  almost  regularly 
occurring  headache.  The  most  dangerous  is  the  disturbance  of  res- 
piration, which  in  certain  cases  has  proceeded  to  fatal  paralysis  of  the 
respiratory  centre.  Some  authors  refer  this  to  the  use  of  the  Trcn- 
delenberg  position  after  injection,  but  this  does  not  coincide  with  the 
experience  of  gynecologists.  If  the  o])eration  necessitates  the  Tren- 
delenberg  position,  it  should  not  be  assumed  until  anesthesia  has 
begun,  in  other  words  vintil  the  drug  has  gone  into  chemical  com- 
bination with  the  nerve  cells. 

Others  lay  the  blame  upon  too  large  a  dose.  Jonnescu  believes  that 
he  can  avoid  respiratory  paralysis  as  well  as  other  disturbances  by 
adding  1/640  grain  of  strychnine  nitrate  to  the  injection.  A  small 
addition  of  suprarenin  to  this  mixture  will  lessen  its  toxic  action. 

In  addition  to  respiratory  ])aralysis  many  authors  descril)e  a  form 
of  muscular  j)aresis,  most  comiiioiily  affecting  the  eye  muscles.  They 
appear  for  the  most  jjart  after  the  lapse  of  a  week,  .ukI  disappear 
again  after  a  short  time.  Disturbances  in  motility  of  the  lower  limbs 
and  in  control  of  the  bladder  and  rectum  seem  to  be  only  temporary, 
although  they  have,  in  certain  cases,  persisted  for  some  time.    Finally 


26  ANESTHESIA 

among  the  deleterious  results  appears  a  group  of  meningeal  irritative 
sj'mptoms,  such  as  neuralgia,  paresthesise,  and  persisting  head  and 
back-aclie.  They  are  the  least  dangerous  of  the  sequelje,  but  they  are 
the  most  pernicious  and  agonizing  for  the  patient,  and  often  resist 
large  doses  of  morphine. 

Spinal  anesthesia  is  on  the  whole  very  well  borne  by  old  patients. 
Bier*  recommends  it  in  particular  for  the  excision  of  carcinoma  of  the 
rectum  and  for  extensive  resection  of  the  bony  pelvis,  and  states  that 
such  jiatients  after  its  use  feel  much  better  than  those  who  have  had 
general  anesthesia.  It  may  be  employed  also  for  the  larger  gyneco- 
logical procedures,  for  instance,  the  Wertheim  extirpation  of  the 
uterus.  The  method  should  not  be  used  in  children,  anemic  and  septic 
patients,  and  all  those  with  affections  of  the  brain,  spinal  cord,  and 
nerves,  particularly  when  the  same  residt  can  be  obtained  with  local 
anesthesia. 

The  preparation  corresponds  to  that  for  general  anesthesia.  The 
patients  would  stand  the  effects  better,  undoubtedly,  if  they  were 
not  obliged  to  fast.  But  fasting  is  necessary  because  it  must  always 
be  reckoned  that  the  method  may  fail  and  that  general  anesthesia  may 
have  to  be  used.  Also  care  must  be  taken  that  the  bladder  and  colon 
are  empty,  for  we  have  observed  soiling  and  fatal  woimd  infection 
after  paralysis  of  these  two  organs.  Scopolamin-morphine  is  used  just 
as  before  inhalation  anesthesia. 

To  carry  out  the  injection  the  patient  sits  across  the  operating  table 
with  his  shoulders  bent  forward  and  legs  hanging.  The  region  of  the 
lumbar  spine  and  the  sacrum  is  painted  with  tincture  of  iodine  and  the 
spinous  process  of  the  second  lumbar  vertebra  is  marked  with  a  fine 
needle  or  with  the  point  of  a  scalpel,  by  a  superficial  scratch.  Exactly 
in  the  middle  line,  in  the  second  himliar  space,  a  fine  trochar  carrying 
a  cannula  is  inserted,  pointing  slightly  upwards,  until  the  patient  ex- 
presses sensitiveness  as  the  spinal  dura  is  penetrated.  The  spinal 
canal  is  successfully  reached  when  upon  witlidrawal  of  the  trochar 
a  clear  liquor  runs  out  of  the  cannula.  In  order  to  prevent  too  great 
a  loss  of  spinal  fluid  the  index  finger  is  placed  over  the  mouth  of  the 
cannula.  Immediately  the  syringe  in  which  the  drug  has  been  pre- 
viously placed,  either  dry  or  dissolved  in  sterile  water  at  a  moderate 
temperature,  is  connected  with  tlie  cannula  and  several  c.c.  of  the  fluid 
aspirated  into  it  in  order  to  make  an  even  mixtm-e  of  the  liquor  and 
the  anesthetic.     Then  under  gradual  pressure  the  contents  of  the 

*Verh.in(i.  der  Deutsch   Ges   f.  Chir,  1909. 


SPINAL  ANESTHESIA  27 

syriiio-e  is  emptied  into  the  dural  canal.  Then  the  syringe  and  the 
trochar  are  jjulled  ont  and  the  skin  puncture  is  sealed  with  gauze. 
Thereupon  the  patient  is  laid  upon  his  back  and  from  time  to  time 
the  progress  of  tiie  anesthesia  is  tested  by  means  of  the  jjoint  of  a 
needle.  It  usually  takes  ten  mimites  for  the  motor  and  sensory 
paralysis  to  reach  the  desired  grade. 

Anesthesia  obtained  with  4  .5  grain  of  tropacocain  on  the  average 
lasts  for  an  hour,  while  stovain  anesthesia  lasts  longer.  First  the 
perineum  becomes  insensitive,  then  the  leg,  and  tinally  the  skin  of  the 
abdomen  as  far  up  as  the  navel.  The  anesthesia  disappears  in  the 
reverse  order.  If  after  an  interval  of  fifteen  minutes  the  anesthesia  is 
absent  or  incomplete,  the  injection  may  be  repeated  in  tlie  same  2)lace 
or  in  the  next  intravertebral  space,  above  or  below. 

Anesthesia  may  be  successfully  induced  to  a  higher  level  than  the 
navel  if  a  higher  intravertebral  space  is  employed  for  the  injection. 
There  is  no  question,  however,  but  that  the  dangers  of  injury  to  the 
cord  and  paralysis  of  respiration  increase  with  the  height  of  injection. 
Jonescu  has  carried  out  the  stovain-strychnine  injeetioti  several  times 
without  fatality  in  the  cervical  cord  itself.  The  danger  of  injury  of 
the  spinal  cord  is  very  small  in  the  region  of  the  third  lumbar  vertebra 
and  below,  for  from  the  second  lumbar  vertebra  down  the  dura  con- 
tains only  the  cauda  equina.  In  this  region  the  broad  cysterna  lum- 
balis  of  the  arachnoideal  sac  protects  the  roots. 

The  upper  limit  of  the  anesthetic  zone  may  be  raised  above  the 
navel  if  after  the  injection  the  patient  be  changed  from  the  horizontal 
to  the  Trendelenberg  y)osition,  and  licld  in  this  position  for  a  short 
time.  In  this  way  the  higher  spinal  roots  are  bathed  in  a  portion  of 
the  solution.  If  this  change  in  position  is  not  made  immediately  after 
the  injection,  the  solution  will  affect  only  the  nerve  roots  proximate 
to  the  point  of  injection:  but  there  is  a  certain  risk  in  assuming  this 
position  just  after  the  introduction  of  the  solution,  as  there  is  danger 
that  fibres  of  the  phremc  nerve  may  be  paralyzed.  l?ut  later  on  this 
position  has  no  prejudicial  effect  oti  the  length  or  the  danger  of  spinal 
anesthesia,  as  may  be  imderstood  from  the  experience  of  gynecologists. 
The  least  dangerous  method  for  extending  the  anesthesia  consists  in 
the  distribution  of  the  anesthetic  over  a  greater  extent  of  the  spinal 
cord.  This  may  be  attained  by  aspirating  more  than  .5  c.c.  of  spinal 
fluid  into  the  syringe  and  reinjecting  it  into  the  dural  canal.  ]?y 
mixing  4/.'>  grain  of  tropacocain  Avith  eight  to  ten  c.c.  of  spinal  fluid 
the  loss  of  .sensibility  as  a  rule  reaches  as  high  as  the  margin  of  the 


28  ANESTHESIA 

ribs,  so  that  even  a  celiotomy  may  be  carried  out  without  pain  and 
without  muscle  spasm. 

Suice  most  failiu'es  depend  upon  faulty  technique,  the  following 
points  must  be  observed  with  particular  care:  It  is  important  tliat  a 
fine  needle  be  employed  so  that  the  injected  fluid  will  not  run  out 
through  the  opening  in  the  dura.  This  will  happen  if  the  punctm-e 
is  large,  because  the  pressure  of  the  fluid  in  the  dural  canal  is  rather 
high,  even  under  normal  conditions.  Quincke  states  that  the  normal 
pressure  varies  from  50  to  1.50  mm.  of  water  and  the  pressure  must 
be  over  200  before  it  can  be  called  abnormal.  This  exjjlains  how,  in 
case  the  internal  pressure  is  increased,  a  certain  amount  of  fluid  may 
be  forced  out  through  the  puncture  before  it  has  time  to  act  upon  the 
nerve  roots.  It  is  also  important  that  the  instruments  which  are 
brought  in  contact  with  the  anesthetic  are  absolutelv  free  from  rem- 
nants  of  soda  bicarbonate,  for  even  minor  traces  of  alkali  will  neutral- 
ize the  solution,  which  is  active  only  in  an  acid  medium.  For  this 
reason  the  necessary  instruments  and  vessels  should  be  sterilized  in 
plain  water  or  any  adhering  soda  must  be  washed  off"  with  salt  solution 
from  all  parts  of  syringe  and  cannula.  If  this  is  omitted,  failures 
will  sometimes  result  therefrom  in  spinal  and  even  in  local  anesthesia. 

Lack  of  skill  in  lumbar  pimcture  may  cause  failure.  To  find  the 
dural  canal  and  inject  the  solution  among  the  roots  without  injin-y  to 
the  cord,  the  puncture  is  made  exactly  in  the  middle  line  in  the  second 
or  third  interlumbar  space.  At  the  level  of  the  first  lumbar  disc  the 
conus  medullaris  frequently  is  not  completely  threaded  out  into  the 
fibres  which  make  up  the  Cauda,  and  its  lower  end  may  be  exposed 
to  injury  from  the  point  of  the  needle.  Such  a  contingency  would 
prevent  the  fluid  from  reaching  the  surroimding  nerve  roots.  The 
same  thing  is  to  be  feared  when  the  needle  is  inserted  from  a  point  to 
one  side  of  the  spinous  process,  or  in  the  lateral  posture.  To  be  sure 
it  is  sometimes  impossible  to  reach  the  dural  canal  through  the  middle 
line  on  account  of  a  kyphosis  of  the  spinal  column :  or  when  the  spinous 
processes  of  the  lumbar  vertebrae  instead  of  being  horizontal  are 
oblique,  and  if  the  intervertebral  space  is  unusually  narrow.  The 
attempt  is  then  made  to  introduce  the  needle  from  the  side,  between 
the  laminje.  In  this  case  the  position  of  the  point  of  the  needle  cannot 
always  be  exactly  located,  and  it  is  possible  that  the  injected  fluid 
comes  in  contact  only  with  the  nerve  roots  on  one  side,  in  which  event 
an  irregular  hemianesthesia  results.  Similarly  it  is  unwise  to  insert 
the  needle  with  the  patient  in  the  lateral  posture  on  account  of  diffi- 


SPINAL  ANESTHESIA  29 

culties  which  arise  in  attempting  to  give  the  needle  the  desired  direc- 
tion. Faihn-e  from  these  sources  may  be  avoided  if  the  patient  is 
seate(l,  with  the  upper  portion  of  the  body  bent  forward  so  that  the 
vertebra?  are  separated  as  far  as  possible. 

If  the  counting  off  and  marking  of  the  second  lumbar  interspace 
has  been  omitted  before  the  disinfection,  the  hem  of  a  sterile  towel  is 
stretched  between  the  crests  of  the  ili;e.  This  will  cross  the  middle 
line  at  the  spine  of  the  fourth  lumbar  vertebra  and  from  this  point 
the  second  space  may  be  easily  arrived  at. 

Another  source  of  failure  lies  in  the  mixture  of  the  solution  with 
blood.  Occasionally  a  certain  amount  of  l)lceding  may  not  be  avoided, 
particidarly  after  puncture  in  the  middle  line.  It  spoils  the  injection, 
because  the  solution  goes  into  chemical  combination  with  the  blood 
before  it  has  a  chance  to  come  in  contact  with  the  nerve  roots.  For 
that  reason  the  fluid  which  flows  from  the  cannula  must  be  as  clear  as 
water.  Bleeding  usually  occurs  when  the  needle  does  not  reach  the 
dural  canal,  but  scrapes  the  surface  of  the  lamina.  \Vhen  this  hapi)ens 
it  nnist  be  slightly  withdrawn,  and  reinserted  in  an  altered  direction. 

Veins  in  the  ligamentum  subflavum  may  be  the  source  of  bleeding, 
particularly  in  punctures  made  from  one  side  of  the  middle  line,  and 
if  the  needle  is  introduced  too  deeply  it  may  meet  veins  lying  along 
the  ojjposite  wall  of  the  dural  canal.  As  long  as  a  blood-tinged  fluid 
appears  from  the  cannula  the  injection  must  be  postponed.  To  avoid 
the  point  of  the  needle  meeting  the  anterior  wall  of  the  dural  canal  it 
should  not  be  introduced  in  thin  persons  deeper  than  5Y2  cm.,  or  in 
obese  persons  more  than  (Jl/)  cm.  If  wlien  the  mandrin  is  removed 
clear  fluid  does  not  flow  out,  it  may  be  obtained  sometimes  by  simply 
twisting  the  cannula.  Before  it  is  pushed  in  deeper  it  should  be  with- 
drawn 1  ^  cm.  or  so  in  order  to  be  sin-e  that  it  has  not  already  met  the 
front  wall  of  the  canal.  If  it  is  to  be  pushed  in  further  the  mandrin 
must  always  be  replaced. 

I.OCAI,  ANESTHESIA 

While  general  anesthesia  is  caused  by  the  influence  of  a  drug  upon 
the  cortex,  local  anesthesia  dejjcnds  upon  tlie  paralysis  of  the  sensory 
nerve  endings  within  the  operative  Held  or  upon  an  interference  with 
the  conductivity  of  the  nerve  tracks  which  supply  the  field  of  operation. 

Of  the  various  methods  which  are  employed  at  the  present  time  for 
instituting  local  anesthesia  many  have  been  in  use  for  a  considcral)le 
period.     For  instance,  cold  has  long  been  known  to  overcome  .sensi- 


30  ANESTHESIA 

hility  to  pain,  and  anesthesia  by  freezing  is  now  induced  by  chemical 
means. 

FREEZING 

Freezing  in  superficial  operations  is  now  accomplished  by  the  use 
of  ethyl  chlorid.  This  highly  volatile  fluid  may  be  obtained  in  glass 
tubes  with  a  spring  stopper.  When  the  stopper  is  removed  the  fluid, 
which  is  volatilized  by  the  warmth  of  tlie  hand,  squirts  out  through 
a  capillary  opening  in  the  neck  of  the  tube.  A  limited  area  or  a  strip 
of  skin  may  by  means  of  this  spray  be  rendered  insensitive  to  pain. 
The  liquid  spray  striking  the  skin  abstracts  the  heat  necessary  for 
its  volatilization,  as  is  shown  by  the  formation  of  a  layer  of  stiff  frost. 
When  this  a])pears,  the  surface  is  ready  for  incision.  It  will  form 
more  rapidly  if  one  blows  meanwhile  upon  the  skin.  If  the  spray  is 
long  continued,  superficial  necrosis  may  result. 

For  the  opening  of  fm'uncles  and  incisions  for  the  removal  of  for- 
eign bodies  or  the  puncture  of  an  aspirating  needle  this  form  of  local 
anesthesia  sufl^ices.  However,  one  must  be  careful  not  to  use  the 
Paquelin  cautery  on  a  surface  frozen  with  ethyl  chlorid,  for  the  prep- 
aration is  inflammable  and  burns  of  the  skin  may  result.  Freezing 
fails  as  soon  as  deeper  layers  of  the  tissues  are  to  be  separated.  In 
order  to  render  regions  below  the  skin  anesthetic  for  operative  pur- 
poses the  employment  of  drugs  by  injection  is  necessary. 

INFILTRATION  AND  CONDUCTION  ANESTHESIA 

COCAIN  AND  ITS  SUBSTITUTES 

The  develojjment  of  local  anesthesia,  which  is  at  the  present  time 
employed  not  only  for  superficial  procedures,  but  for  almost  all  known 
operations,  began  with  the  introduction  of  cocain  into  ophthalmology 
by  Roller.  Cocain  has  a  strong  toxic  action  wliicli  even  after  the 
injection  of  small  doses  may  induce  collapse  and  fainting  and  in  larger 
doses  cramps  and  paralysis  of  respiration  and  of  the  heart.  With 
a  maximum  dose  of  4/5  grain  evidences  of  toxic  action  may  appear. 
In  no  case  should  the  amount  used  in  any  given  operation  exceed 
ll/>  grains.  Moreover,  cocain  diluted  to  1  per  cent,  may  cause  active 
symptoms  of  irritation  at  the  site  of  injection,  but  the  burning  pain 
disappears  as  soon  as  the  drug  has  taken  effect  upon  the  nerves. 

In  spite  of  its  toxicity  and  the  irritation  which  it  causes,  cocain  is 
still  used  to-day  for  superficial  anesthesia  of  the  mucous  membranes  of 


INFILTRATION  AND  CONDUCTION  ANESTHESIA  31 

the  nose,  pharynx  and  mouth.  Strong  sohitions  of  five  to  twenty 
per  cent,  are  used;  they  are  apphed  by  means  of  a  sterile  brush  or  a 
pledget  of  absorbent  cotton.  In  the  conjunctiva  of  the  eye  a  three 
to  ten  per  cent,  solution  is  instilled.  Within  a  few  minutes  anesthesia 
occurs,  followed  immediately  by  a  strong  anemic  action,  so  that  super- 
ficial procedures  may  be  carried  out  with  a  clear  field  and  without  pain. 

The  infrc(|uency  of  cocaiii  poisoning  in  s])ite  of  its  use  in  strong 
concentrations  as  a  local  application  depends  upon  the  slow  absorp- 
tion, which  residts  from  the  contraction  of  the  vessels,  liut  toxic 
symptoms  are  always  possible.  They  are  especially  likely  to  appear 
if  cocain  is  injected  under  pressin-e  into  the  meshes  of  the  skin  or  into 
closed  cavities  such  as  the  bladder.  On  this  account  its  use  even  in 
mild  solutions  is  being  given  up  for  less  dangerous  and  at  the  same 
time  less  anesthetic  preparations  such  as  eucain,  alypin,  tropococain 
and  particidarly  novocain.  Novocain  has  given  general  satisfaction 
on  account  of  its  freedom  from  local  irritation,  so  that  injections  may 
be  made  without  pain  and  without  later  disturbances  of  the  nutrition 
of  the  tissue,  and  on  account  of  its  high  relative  freedom  from  toxicity; 
it  is  much  less  toxic  than  cocain  and  large  quantities  may  be  injected 
into  the  skin  without  danger. 

For  the  j)roduction  of  local  anesthesia  many  methods  are  described. 
The  widely  usud  ScJiIcic}/  infUtrdtion  7Hc///or/ consists  in  satin-ating  the 
tissues  by  layers  in  considerable  quantities  of  a  very  weak  cocain  solu- 
tion. A  wheal  appears  as  the  residt  of  the  first  subepidermal  injection, 
and  a  line  of  these  is  created  across  the  operating  field,  corresponding 
to  the  line  of  incision,  by  inserting  the  needle  each  time  obliquely  at 
the  edge  of  the  wheal  just  created.  Then  through  this  insensitive  field 
the  dermis  is  infiltrated.  After  the  skin  is  divided,  the  deeper  layers 
are  infiltrated  and  cut.  With  this  technique  the  tissues  are  puffed 
with  fluid,  and  assume  a  glassy  aspect,  so  that  the  normal  appearances 
are  considerably  disturbed.  The  lack  of  sensibility  to  ])ain  depends 
upon  the  fact  that  the  nerves  are  saturated  with  the  solution  at  the 
same  time  as  the  other  tissues. 

Conduclion  ancsflic.sia  consists  in  a  pai-alysis  of  the  nerves  which 
go  to  the  operative  field.  Ilackenbrueh  arrives  at  this  result  by 
making  a  series  of  injections  encircling  the  field  without  infiltrating 
the  skin  or  the  subcutaneous  tissue  of  the  operative  site  Itscli'.  Since 
all  the  nerves  going  to  the  operative  field  must  be  met  in  such  a  ])i()- 
cedure,  anesthesia  through  infiltration  is  unnecessary.  The  method 
of  Oberst  in  the  same  way  depends  upon  a  paralysis  of  nerve  con- 


32  ANESTHESIA 

ductivit}'.  In  operating  upon  fingers  and  toes  tlie  nerves  wliicli  go  to 
the  middle  and  the  terminal  plialanges  are  met  in  the  connective  tissue 
close  to  the  periosteum  of  the  first  phalanx,  as  near  as  possible  to  the 
hand  or  foot,  by  means  of  a  series  of  injections  completely  surround- 
ing the  digit.  The  effect  of  the  anesthetic  is  increased  by  fii'st  render- 
ing the  part  anemic  by  means  of  an  Esmarch  bandage  and  turniquet, 
because  in  a  part  which  is  empty  of  blood  and  with  the  circulation 
interrupted,  absorption  is  hindered  and  the  local  effect  is  increased. 
The  same  effect  may  be  obtained  by  the  use  of  suprarenin.  Braun 
originated  a  similar  procediu'c  for  the  amputation  of  limbs.  After 
Esmarch  anemia  has  been  obtained,  the  cocain  solution  is  injected 
close  to  or  about  the  nerves  which  supply  the  limb  so  that  the  solution 
may  diffuse  into  their  substance.  ^Nlore  advantageous  is  the  endo- 
neural method  of  Gushing,  INIatas  and  Crile,  by  which  each  separate 
nerve  trunk  is  freed  up  by  dissection  and  the  injection  made  directly 
into  its  substance. 

Each  of  these  various  methods  has  its  own  peculiar  disadvantages, 
with  the  single  exception  of  the  method  of  Oberst,  which  prevent  their 
general  employment.  The  painfidness  of  the  wheal  formation  at  the 
beginning  of  infiltration  anesthesia,  and  of  the  application  of  the 
Esmarch  bandage  in  regional  anesthesia,  the  unnatural  ajipearance 
of  the  tissues,  which  are  swollen  with  fluid  from  the  injection,  and 
finally  the  danger  of  poisoning  even  when  a  small  quantity  of  cocain 
is  used,  added  to  the  difficulties  of  technique  for  a  long  time  created 
a  prejudice  against  local  anesthesia,  so  that  frequently,  even  where 
it  might  properly  be  used,  inhalation  anesthesia  was  given  the  pref- 
erence. The  swing  in  the  pendulum  began  with  the  recommendation 
of  Braun  that  cocain  might  be  replaced  liy  the  non-toxic  and  unirri- 
tating  novocain,  and  its  present  popularity  began  to  develop  with  his 
discovery  of  the  advantage  of  the  addition  of  suprarenin  to  the 
solution. 

braun's  procedure 

The  active  principle  of  the  extract  of  the  suprarenal  gland,  first 
recoo-nized  bv  Furth  and  obtained  in  crvstalline  form  bv  Takamine. 
possesses  the  power  of  inducing  strong  contraction  of  the  blood 
vessels,  and  as  a  result,  of  producing  an  almost  bloodless  zone  in  the 
tissues.  This  effect  appears  even  if  the  drug  is  strongly  diluted. 
When  it  became  possible  to  produce  the  drug  s\nithetically  and  chem- 
ically pure,  which  could  even  withstand  sterilization  by  boiling  for  a 


BRAUN'S  PROCEDURE  33 

short  period,  no  further  theoretical  objection  to  its  use  for  injection 
appeared.  Ten  to  fifteen  drops  of  one  to  a  tliousand  sokition  in 
100  c.c.  of  a  1  o  per  cent,  novocain  sohition  a(hiiirahly  answers  all 
purposes.  In  a  short  time  after  the  injection  an  anemia  of  hi<^h 
degree  appears  at  the  site  of  injection,  which  is  equivalent  to  tlie 
anemia  obtained  by  the  procedure  of  Ksmarch.  As  the  result  of  the 
reduced  or  practically  suspended  circulation  of  the  injected  limb,  an 
early  absorption  of  the  (lru<>'  takes  ])lace.  and  at  the  same  time  its 
general  toxic  action  is  limited  and  its  local  effect  increased.  For  this 
reason  when  combined  with  suprarenal  extract  only  small  quantities 
of  novocain  are  necessary.  But  on  the  other  hand  larger  quantities 
of  no\ocain  may  be  used,  if  the  operation  is  extensive  enough  to  make 
it  necessary,  without  causing  danger  of  poisoning. 

By  means  of  this  combination  of  the  anesthetic  with  suprarenin  it 
was  first  successfully  bi-ought  about  that  the  slow  and  often  painful 
infiltration  anesthesia  of  Schleich.  limited  in  its  application  to  the 
subcutaneous  tissues,  and  conduction  anesthesia  for  the  deeper  parts, 
might  be  c()ml)ined  and  developed  as  the  basis  of  a  safe  and  harmless 
method  of  wider  application.  And  moreover  it  became  unnecessary 
to  inject  directly  the  nerves  which  serve  the  operative  field,  for  as  a 
result  of  the  anemia-inducing  action  of  the  suprarenin  the  anesthetic 
remains  for  a  longer  time  at  the  site  of  injection,  and  if  this  occurs 
in  the  neighborhood  of  a  nerve,  it  diffuses  into  it  sufficiently  to  over- 
come its  conductivity. 

^U) VANTAGES  AND  DISADVANTAGES  OF  LOCAL  ANESTHESIA 

While  at  first  local  anesthesia  was  limited  in  its  applicability  to 
minor  surgery,  with  the  recognition  of  the  advantage  of  the  com- 
bination of  novocain  and  sui^rarenin  and  with  the  development  of  the 
technique  of  injection,  the  field  has  gradually  b'oadened,  so  that 
to-day  it  has  become  possible  to  employ  it  for  all  the  ty2)ical  operations 
upon  the  head,  trunk  and  extremities  without  pain  and  without  the 
aid  of  inhalation  anesthesia.  For  certain  operations  local  anesthesia 
is  practically  necessary,  because  general  anesthesia  is  contra-indicated. 
This  is  true  of  all  procedures  upon  the  air  j)assages  and  in  their 
vicinity.  It  is  indicated  also  in  all  cases  in  which  tlic  danger  of  general 
anesthesia  is  out  of  proportion  to  the  importance  of  the  operation, 
and  when  disease  of  heart  nniscle  forbids  inhalation  anesthesia.  The 
harmlessness  of  local  anesthesia  is  its  greatest  advantage. 

In  spite  of  recent  wide  extension  of  its  use  in  major  surgery,  it 


m  ANESTHESIA 

would  not  be  advisable  to  consider  that  local  anesthesia  can  replace 
general  anesthesia  in  every  case,  for  there  always  remains  a  certain 
class  of  patients  in  whom  the  procedure  for  technical  reasons  cannot 
readily  be  carried  out,  or  whose  psychic  state  contra-indicates  its  use. 
Even  when  nervous  pertiu'bance  and  anxiety  have  been  largely  over- 
come by  the  previous  use  of  scopolamin-niorphine,  which  we  never  omit 
in  large  operations  under  local  anesthesia,  the  excitation  of  such 
patients,  during  the  operation,  may  increase  to  such  a  stage  that  it  is 
not  without  danger  to  the  heart  and  mind,  and  the  bodily  agitation 
also  endangers  asepsis.  JNIost  of  the  patients  who  have  been  trephined 
under  local  anesthesia  state  that  they  have  felt  no  pain  from  the  in- 
cision, but  the  sawinnj  and  chiseling  of  the  bone  brings  back  frightful 
memories.  And  the  psychic  trauma  arising  during  the  preparation 
and  the  course  of  the  operation  is  not  to  be  looked  upon  lightly,  and 
in  order  to  impress  this,  it  is  necessary  only  to  recall  the  reports  from 
the  period  before  the  use  of  anesthetics,  according  to  which  patients 
have  died  in  shock  waiting  for  a  tootli  or  nail  to  be  extracted.  Hysteri- 
cal and  nervous  patients  and  most  children  are  not  fit  subjects  for 
local  anesthesia,  and  on  humanitarian  grounds  it  is  onlv  right  that  if 
a  patient  desires  general  anesthesia  it  should  be  given,  if  there  is  no 
contra-indication. 

Certain  physical  conditions  contra-indicate  the  general  employment 
of  local  anesthesia  more  definitely  even  than  mental  states.  It  is  to  be 
regretted  that  the  very  patients  who  cannot  stand  general  anesthesia 
on  physical  grounds  are  also  poor  subjects  for  local  anesthesia. 
Among  these  all  cases  of  sepsis  which  are  not  definitely  localized,  and 
advanced  arteriosclerosis,  particularly  when  it  is  combined  with  gan- 
grene or  diabetes,  are  to  be  reckoned.  Also  it  must  be  stated  as  a 
principle  that  malignant  growths  should  not  be  removed  under  local 
anesthesia,  because  the  insensitive  field  of  the  conduction  anesthesia 
is  limited,  and  the  coiu'se  of  the  operation  not  infrequently  makes  it 
necessary  to  overstep  the  bounds. 

With  the  exception  of  hernia  we  can  find  no  advantage  in  the  em- 
ployment of  local  anesthesia  for  celiotomies.  The  abdominal  wall  can 
always  be  opened  without  pain,  but  handling,  tying  and  cutting  in 
all  portions  of  the  mesentery  cause  agony.  Fainting  with  weakening 
of  the  pidse.  and  distiu-bing  pallor,  may  be  the  accompaniment  of  a 
rapidly  carried  out  appendectomy  as  soon  as  tying  off  of  the  meso- 
appendix  is  begun.  Also  in  patients  who  are  reduced  by  starvation 
as  the  result  of  stricture  of  the  pylorus  or  at  the  cardiac  end  of  the 


INDICATIONS  FOR  LOCAL  ANESTHESIA  35 

stomach,  the  estabhshnient  of  a  gastro-enterostoniy  or  of  a  gastric 
fistula  under  local  anesthesia  has  no  advantage  over  inhalation  anes- 
thesia. One  can  readily  succeed  in  reachino-  the  stomacJi  without  pain 
in  every  case,  but  the  collapse  and  the  reflex  shock  caused  by  the 
handliiig  of  the  viscera  of  a  patient  who  is  not  completely  anesthetised 
is  at  least  as  dangerous  as  the  small  amount  of  anesthetic  necessaiy  to 
put  such  an  emaciated  and  weak  patient  to  sleep.  iVnd  the  proportion 
of  fatalities  during  the  first  week  after  establishment  of  a  gastrostomy 
un<ler  local  anesthesia  is  no  less  than  under  general  anesthesia.  And 
moreover  it  can  be  said  definitely  that  post-operative  pneumonia  after 
celiotomy  does  not  disappear  with  the  employment  of  local  anesthesia. 
Although  we  have  for  a  considerable  time  carried  out  operations  under 
local  anesthesia  on  aseptic  and  uncomplicated  stomach  cases,  inguinal 
hernias  and  interval  appendices,  without  picking  patients  in  whom 
inhalation  anesthesia  might  be  contra-indicated  on  any  grounds, 
several  of  these  did  not  forbear  to  develop  on  the  second  or  third  day 
a  typical  brojicho-pneumonia.  None  of  those  so  operated  on  died, 
but  the  fact  itself  has  determined  us  to  employ  local  anesthesia  in 
laparotomies  only  when  some  definite  contra-indication  to  general 
narcosis  exists. 

Finally  one  other  circumstance  cannot  be  omitted  in  considering  the 
subject  of  the  general  application  of  local  anesthesia.  Cocain  and 
novocain  do  not  allow  of  the  most  acceptable  sterilization,  and  supra- 
reniu  is  particularly  sensitive  to  boiling.  It  breaks  up  just  as  cocain 
does  when  once  heated,  so  that  the  solution  cannot  be  satisfactorily 
sterilized.  In  the  same  way  the  tablets  of  novocain  and  suprarcnin 
which  are  on  the  market  and  are  said  to  be  free  from  bacteria,  show 
the  presence  of  bacteria  when  the  solution  is  prepared.  We  have  had 
one  fatal  case  of  infection  following  the  extirpation  of  the  Gasserian 
ganglion,  resulting  from  not  boiling  the  solution  before  injecting. 
Previous  to  this  case  no  single  anesthesia  with  the  so-called  bacteria- 
free  tablets  sim])ly  dissolved  in  sterile  salt  solution  had  resulted  in 
infection.  Hut  on  the  other  hand  it  has  been  found  to  be  a  rule  that 
novocain-suprarenin  solution  after  efficient  sterilization  loses  a  good 
part  of  its  activity,  and  that  boiling  the  solution  once  does  not  sufTice 
to  kill  all  pathological  bacteria,  and  we  consider  ourselves  justified  in 
laying  the  blame  of  the  infection  in  this  case  upon  the  injection, 
because  in  eighty-one  extirpations  of  the  Gasserian  ganglion  carried 
out  under  exactly  the  same  conditions  there  appeared  no  disturbance 
of  asepsis. 


36  ANESTHESIA 

TECHNIQUE  OF  LOCAL  ANESTHESIA 

For  injection  we  use  an  all-glass  syringe  holding  five  or  ten  c.c,  to 
which  thin  needles  of  various  lengths,  straight  and  angular,  may  be 
attached  by  means  of  a  push  or  bayonet  joint,  which  allow  ready 
removal  of  the  empty  syringe,  and  the  attachment  of  a  freshly  filled 
one,  without  disturbing  the  needle.  All  instruments  and  vessels  with 
which  the  novocain  solution  is  brought  into  contact  are  not  allowed 
to  be  boiled  in  soda  solution,  as  even  traces  of  alkali  break  up  the 
suprarenin  and  the  novocain  and  render  them  useless. 

To  make  this  solution  we  use  a  novocain-suprarenin  tablet  which 
contains  2  grains  of  novocain  and  1  jOO  grahi  of  L-suprarenin.  One 
tablet  is  dissolved  in  7  drams  of  physiological  salt  solution,  which  gives 
a  1/)  per  cent,  solution,  which  suffices  for  infiltration  and  usually  also 
for  conduction  anesthesia.  Although  the  tablet  is  guaranteed  sterile, 
nevertheless  in  our  experience  several  cases  have  shown  this  to  be 
uncertain.  For  that  reason  we  employ  the  method  of  H.  Braun  for 
making  and  sterilizing  the  solution.  He  advises  that  one,  two  or  four 
tablets  be  placed  in  a  sterile  test  tube  and  covered  with  physiological 
salt  solution,  to  each  liter  of  which  three  drops  of  diluted  hydrochloric 
acid  have  been  added,  and  dissolved  by  boiling.  This  stock  solution 
may  be  diluted  to  any  strength  by  the  addition  of  sterile  physiological 
salt  solution. 

ANESTHESIA  OF  THE  SUPERFICIAL  AND  DEEP  TISSUES 

Local  anesthesia  is  best  adapted  for  the  superficies  of  the  body,  since 
a  series  of  injections  into  the  areolar  sub-dermal  or  sub-mucous  con- 
nective tissue  after  the  method  of  Hackenbruch  can  be  relied  upon 
to  destroy  all  sensibility.  As  all  the  sensory  nerves  reach  the  skin 
and  the  mucous  membrane  through  the  connective  tissue,  the  solution 
after  a  little  time  will  diffuse  sufficiently  into  the  nerve  bundles. 
Accordingly,  circumferential  injection  suffices  for  small  wounds  or 
foci  of  disease,  such  as  furuncles,  papilloniata  and  small  tumors, 
but  for  lipoma  and  larger  fibroma,  sebaceous  and  mucous  cysts 
and  other  more  extensive  growths,  which  penetrate  into  the  sub- 
jacent tissues,  an  injection  of  the  deep  layers  is  also  necessary, 
^lovable  tumors  should  be  lifted  up  as  much  as  possible  so  that  the 
needle  does  not  enter  the  tumor  but  the  loose  tissue  about  it.  Xat- 
la-ally  it  will  often  be  necessary  to  make  injections  even  under  the 
fascia  in  order  to  block  the  nerves  there.  While  anesthesia  appears 
rajiidly  in  small  blocked-out  fields  in  the  skin  or  mucous  membrane, 


NERVE  BLOCKING  37 

in  more  extensive  blocking  and  in  subfascial  injection  a  longer  time, 
five  to  twenty  minutes,  is  necessary.  Braun  explains  this  by  saying 
that  the  terminal  nerve  filaments  which  are  without  sheaths  in  the 
vicinity  of  the  end  organs  take  up  the  anesthetic  more  rapidly  than 
the  larger  ner\e  trunks.  With  these  the  diffusion  of  the  injected 
fluid  acts  slower,  because  the  fibres  as  well  as  the  larger  bundles  are 
surrounded  by  a  jjrotective  sheath,  which  becomes  thicker  as  the 
nerve  j)roceeds  toward  the  cord. 

Ujion  this  principle  depends  om-  method  of  anesthetization  of  the 
deep  layers  of  tissue.  Utilizing  om*  kTiowledge  of  anatomy,  we 
attempt  to  inject  a  few  centimetres  of  the  solution  as  near  as  possible 
to  the  nerve  fibres  Avhich  supply  the  operative  field.  As  soon  as  this 
has  been  done  to  all  of  the  nerves  which  have  to  be  taken  into  account, 
the  deep  layers  of  the  skin  are  infiltrated  in  a  broad  strip,  which 
covers  the  line  of  incision.  This  injection  is  made  last,  because  the 
anesthesia  of  the  skin  occurs  very  rapidly.  The  deep  layers  become 
insensitive  after  an  interval  of  about  fifteen  to  twenty  minutes,  and 
remain  so  for  about  an  hour. 

lU.OCKIXG  OF  LARGE   NER\^  TRI^NKS 

For  the  blocking  of  large  nerve  trunks  we  never  use  a  solution 
stronger  than  \'-2  of  1  ])er  cent.,  although  as  strong  as  1  or  2  per  cent. 
has  been  recommendcfl.  The  quantity  of  injected  solution,  however, 
as  we  have  shown,  is  not  an  important  matter,  and  we  have  never 
seen  evidences  of  toxic  alisorption.  although  Ave  have  used  at  times 
more  than  5  ounces  of  the  \{>  per  cent,  solution.  If  it  happens  that 
an  injection  does  not  reach  the  vicinity  of  the  nerve,  another  attempt 
must  be  made. 

In  fat  patients  it  is  hard  to  reckon  the  depths  of  the  nerve,  as  this 
may  not  be  constant.  One  will  succeed  much  more  readily  in  reach- 
ing the  neighborhood  of  the  nerve  if  its  location  is  determined  by  a 
bony  prominence  or  by  some  other  readily  palpable  landmark. 

CIRCUMINJECTION  OF  THE  AT.SSEI.S 

The  proximity  of  large  vessels  is  not  particularly  a  matter  of 
anxiety  so  far  as  the  injection  goes.  One  cannot  always  avoid  meeting 
them.  :ni(l  in  ordir  to  recogm'ze  the  injury  immediately  we  use  the 
following  scheme:  The  needle  is  introduced  attached  to  the  syringe, 
and  as  soon  as  the  jxiint  has  reached  the  desired  ])lace  the  piston  is 


38  ANESTHESIA 

slif^htly  withdrawn.  If  blood  is  sucked  into  the  cyHnder,  the  needle 
is  drawn  back  and  reinserted  in  another  direction.  By  the  color  of 
the  blood  one  may  recognize  whether  a  vein  or  artery  has  been  injured; 
in  either  case  the  incident  should  have  no  result  upon  the  anesthesia. 
Even  when  the  solution  is  injected  not  into  the  tissues,  but  into 
a  vessel,  no  harm  results.  In  order  to  make  as  small  a  wound 
in  the  vessel  as  possible  in  all  deeply  penetrating  injections, 
we  make  use  of  as  fine  a  needle  as  possible,  which  adds  some- 
thing to  the  difficidty  of  the  injection.  If  the  bleeding  from  the 
punctiu'e  does  not  stop  immediately,  temporary  light  pressure  with 
a  sponge  will  overcome  it.  JNIoreover,  the  tiny  wounds  of  the  ves- 
sel wall  close  themselves  rapidly  under  the  influence  of  the  supra- 
renin. 

This  vaso-constrictive  action  is  also  of  significance  in  other  respects 
in  carrying  out  conduction  anesthesia  in  the  deep  tissues.  To  induce 
anesthesia  injection  about  the  nerves  is  sufficient,  but  in  conjunction 
with  the  loss  of  sensibility  to  pain  one  also  obtains  usually  an  excel- 
lently clear  field  which  is  not  in  the  least  obstructed  by  bleeding. 
This  residts  from  the  fact  that  the  vessels  and  nerves  run  together 
practically  all  over  the  body,  and  both  are  equally  affected  by  the 
influence  of  the  suprarenin.  Where  this  is  not  the  case,  for  instance 
in  isolated  venous  plexuses,  lying  upon  muscle  or  bone,  or  in  the 
case  of  arteries  running  by  themselves,  one  can  induce  anemia  of  the 
operative  field  by  injecting  the  solution  about  these  vessels,  in  addition 
to  the  perineural  injection.  This  does  not  always  follow,  but  we  have 
carried  it  out  satisfactorily  several  times,  particularly  in  procedures 
upon  the  skidl. 

The  amount  of  suprarenin  contained  in  the  tablet  is  sufficient  to 
induce  a  complete  closure  of  the  small  vessels  and  a  narrowing  of  the 
larger  ones,  but  its  influence  is  not  sufficient  to  stop  bleeding  from 
the  large  vessels.  This  is  of  importance  as  regards  the  final  hemostasis, 
as  all  the  bleeding  points  which  ajjpear  during  the  operation  and  which 
represent  vessels  which  have  become  anemic  under  the  influence  of 
the  suprarenin  must  be  caught  and  tied,  if  there  is  to  be  no  question  of 
secondary  bleeding  and  hematoma  formation  after  the  operation. 
Tying  of  the  vessels  will  be  found  very  painful  if  the  anesthesia  is 
inadequate,  and  for  that  reason  it  is  necessary  in  order  to  create  a 
satisfactory  anesthesia  to  carry  out  the  separate  injection  of  the  nerves 
and  the  vessels,  in  so  far  as  they  are  separated  from  each  other. 


SPECIAT,  PROCEnURES  39 

CIRCULAR  IXJECTIOX  OF  THE  SOFT  PARTS  AXO  BONE 

All  the  reiiiaiiiiii<>-  soft  parts  which  lie  in  the  deeper  layers  of  the 
body  may  be  rendered  anesthetic  in  a  similar  way  thr(ni(>h  conduction 
anesthesia.  The  braui  and  most  of  the  viscera  as  well  as  bone  possess 
themselves  a  very  low  grade  of  sensibility  and  no  jjarticular  experi- 
ence is  necessary  in  order  to  operate  upon  them  painlessly,  but  on  the 
other  hand  the  j)arietal  layers  of  the  pleura  and  of  the  j)eritoneum, 
tendon  sheaths,  wide  muscle  fascia;  and  aponeuroses,  the  dura  mater 
and  periosteum  as  well  as  the  perichondrium,  are  usually  sensitive. 
But  since  their  nerves  lie  outside  of  the  organs  which  they  protect,  to 
induce  anesthesia  it  is  sufficient  to  inject  superficially  the  sections 
which  fall  within  the  operating  field. 

Peritoneum  and  transversalis  fascia  are  also  so  insensitive  that  for 
them  a  circumferential  injection  of  the  connective  tissue  under  the 
deepest  layer  of  abdominal  muscle  suffices.  A  special  injection  of  the 
fascia  or  even  of  the  peritoneum  is  unnecessary.  In  thin  belly  walls 
the  danger  of  puncture  of  the  peritoneum  is  very  slight,  because  if 
the  needle  is  introduced  slowly  the  resistance  of  the  transversalis  fascia 
can  be  felt  distinctly.  In  muscular  and  fatty  abdominal  walls  one 
cannot  always  depend  upon  introducing  the  needle  to  the  desired  level, 
so  as  just  to  feel  the  resistance  of  the  transversalis  fascia. 

In  the  same  way  it  is  unnecessary  to  introduce  the  solution  imder 
the  periosteum  in  order  to  operate  without  pain  on  the  periosteum 
and  bone.  From  the  connective  tissue  between  it  and  the  soft  parts 
which  surround  it  the  nerves  and  vessels  penetrate  to  it  and  likewise 
to  the  bone  itself,  and  it  is  at  this  point  that  the  conductivity  is  in- 
terrupted. 

]\Iuscles  are  the  most  sensitive  at  the  place  where  the  nutritive 
vessels  and  nerves  enter,  but  large  sections  are  so  insensitive  as  to  allow 
themselves  to  be  cut  Avithout  pain,  even  without  anesthesia.  Similarly 
operations  may  be  performed  without  pain  on  the  long  tendons;  they 
are  sensitive  and  require  anesthesia  only  where  they  are  covered  by 
tendon  sheaths.  Bone,  muscle  and  tendon  are  all  anesthetized  on  the 
same  ])rinciple.  that  is  by  the  saturation  with  the  anesthetic  of  the 
connective  tissue  which  surrounds  them  and  which  contains  the  nerves 
and  vessels  which  go  to  them,  from  several  points  in  front  and  behind, 
above  and  below. 

SPECIAL    PROCEniTRES 

In  accordance  with  these  general  remarks  it  is  evident  that  as  many 
methods  may  be  conceived  for  its  accomplishment  as  there  are  oj)era- 


40  ANESTHESIA 

tions.  Any  one  who  understands  the  mechanism  of  anesthesia  and  is 
acquainted  with  the  course  of  the  more  important  nerves  can  in  any 
])articular  case  easily  and  satisfactorily  render  the  operating  field 
insensitive.  For  that  reason  it  is  unnecessary  to  explain  methods  for 
conducting  an  operation  under  local  anesthesia  which  are  self-evident. 
But  one  must  recognize  the  value  of  the  work  of  Braun,  who  first 
showed  the  advantage  of  joining  suprarenin  with  the  anesthetic  agent, 
and  of  combining  infiltration  and  conduction  anesthesia,  by  which 
cocaine  operations  are  no.  longer  limited  to  minor  procedures  upon  the 
peripheral  portions  of  the  body,  but  are  extending  rapidly  to  include 
complicated  cases  in  the  depths  and  in  the  large  body  cavities. 

LAMINECTOMY 

Some  time  ago  we  did  our  first  laminectomy  under  novocain-supra- 
renin  anesthesia.  The  fluid  was  injected  a  few  finger-breadths  above 
and  below  the  spinous  process  of  each  vertebra  involved.  After  a  few 
wheals  were  formed  in  the  middle  line  along  the  planned-out  incision, 
in  order  to  make  the  skin  insensitive  to  the  deep  punctures,  the  needle 
was  next  inserted  through  the  wheal  to  one  side  of  the  spinous  process 
down  to  the  lamina,  and  by  elevating  and  then  depressing  the  point, 
about  .5  c.c.  was  injected  above  and  below.  Then  it  was  drawn  nearly 
out  and  passed  down  the  other  side  of  the  spinous  process,  where  the 
same  procedin-e  was  repeated.  This  process  was  carried  out  for  each 
of  the  wheals.  Before  the  needle  was  completely  withdrawn,  the  skin 
was  rendered  insensitive  by  subcutaneous  injection. 

Incision  of  the  skin  and  muscle  as  well  as  the  removal  of  the 
periosteum  from  the  spinous  processes  and  laminae  were  entirely  pain- 
less and  there  was  practically  no  bleeding.  The  trephining  of  the 
lamina  was  painless  and,  following  this,  the  cutting  of  the  lamina  with 
the  laminectome  was  painful  as  often  as  the  instrument  came  in  con- 
tact with  the  dura.  If  this  was  avoided,  however,  the  biting  off  of  the 
remnants  of  the  lamina  with  the  rongeiu's  was  hardly  to  be  felt.  Pain 
was  only  experienced  during  the  extradural  probing  between  the  dura 
and  the  laminae  and  in  sponging  the  dura,  and  with  every  contact  with 
the  posterior  surface  of  the  cord,  and  particularly  the  posterior  roots. 

TREPHINING 

We  have  also  employed  local  anesthesia  for  trephining,  in  the 
attempt  to  avoid  the  dangers  and  injurious  effects  of  a  general  anes- 
thetic.    The  technique  of  this  procedure  presents  no  difficulties;  it 


TREPHINING  41 

consists  of  a  circumferential  infiltration  of  the  field  of  operation, 
under  the  aponeurosis  as  well  as  subcutaneousl}^  from  various  points. 
It  is  unnecessary  to  insert  the  needle  under  the  periosteum,  and  this  is 
witiiout  any  advantage,  and  causes  pain.  Anestliesia  of  the  peri- 
osteum and  bone  appears  in  ten  to  fifteen  mimites.  Injection  renders 
unnecessary  special  procedures  for  hemostasis,  for  witliin  the  given 
time  the  field  which  has  been  encircled  by  injections  becomes  so  empty 
of  blood  that  few  if  any  vessels  ha\'e  to  be  caught  and  tied.  In  tre- 
phining over  the  cerebellinii  the  depth  of  the  occipital  fossa  makes  it 
necessary  to  introduce  the  needle  throvigh  the  entire  mass  of  the 
muscles  of  the  neck.  A  separate  injection  should  always  be  made  in 
the  neighboi-hood  of  the  occipital  artery,  which  may  be  met  near  the 
tip  of  the  mastoid  process  behind  the  sterno-mastoid  muscle. 

In  spite  of  the  fact  that  the  technique  of  local  anesthesia  for  tre- 
phining presents  no  difficulties  and  that  anesthesia  may  be  induced 
with  assurance,  it  is  a  question  whether  the  procedure  presents  uncon- 
ditional advantages  for  the  patient.  For  trephine  cases  the  contra- 
indications which  we  have  noted  above  hold  against  a  too  general  em- 
ployment of  local  anesthesia.  The  psychic  influence  of  fear  and 
anxiety  are  not  to  be  taken  lightly,  and  scopolamin-morphine  cannot 
be  employed  for  brain  tvmiors  because  the  cardiac  and  respiratory 
centres  are  usually  damaged  from  increased  intracranial  pressure  and 
the  scopolamin  works  a  similar  paralytic  effect.  The  patients  are 
usually  considerably  stirred  up  during  the  cutting  of  the  trap  door 
in  the  skull  and  they  complain  considerably  during  the  process,  and 
for  a  long  time  afterward,  because  they  have  been  deprived  of  the 
advantages  of  general  anesthesia.  JVIoreover,  we  have  several  times 
had  the  experience  that  patients  after  the  injection  fall  into  a  deep 
sleep,  out  of  which  they  awaken  foi-  a  moment,  but  do  not  stay  awake 
long  enough  to  take  a  deep  breath.  Particularly  we  would  like  to 
call  attention  to  the  fact  that  one  patient  with  a  tumor  of  the  temporal 
lobe  in  whom  local  anesthesia  was  employed  without  the  prophylactic 
scopolamin  injection  succumbed  as  the  tumor,  which  had  grown  onto 
the  dura,  was  lifted  out,  without  it  being  possil)le  to  (hffcrentiate  the 
manner  of  death  from  such  as  is  sometimes  observed  in  brain  cases 
wliich  have  had  general  anesthesia. 

OPERATIONS  ON   THE  FACE 

Procedures  on  the  face  may  as  a  whole  be  carried  out  very  satis- 
factorilv  under  local  anesthesia,  because  the  branches  of  the  trifacial 


42  ANESTHESIA 

nerve  are  readily  accessible  to  injection  outside  of  the  skull.  Thus 
the  frontal  nerve  may  be  found  at  the  supra-orbital  notch,  the  infra- 
orbital nerve  at  the  infra-orbital  foramen,  or,  deeper,  on  the  floor  of 
the  orbit,  the  inferior  dental  nerve  inside  the  mouth  just  above  the 
lingula,  which  projects  over  the  inferior  dental  foramen  of  the  lower 
jaw,  and  the  lingual  nerve  at  the  side  of  the  mouth  in  the  fold  of 
mucous  membrane  between  the  tongue  and  the  floor  of  the  mouth. 
The  teeth  of  the  upper  jaw  may  be  rendered  insensitive  by  injection 
at  the  juncture  of  the  gum  with  the  mucous  membrane  of  the  lip, 
although  a  considerable  time  must  elapse  to  allow  the  fluid  to  diffuse 
through  the  thin  shell  of  bone  comprising  the  outer  wall  of  the  antrum 
of  Highmore.  H.  Braun  has  shown  that  in  the  extraction  of  upper 
teeth  the  gum  about  them  should  always  be  injected.  The  lower  teeth 
may  be  readily  anesthetized  through  an  injection  of  5  c.c.  above  where 
the  hngula  of  the  lower  jaw  can  be  felt  with  the  finger. 

To  carry  out  extensive  operations  upon  the  soft  parts  of  the  face 
such  peripheral  injection  does  not  suffice  to  create  a  satisfactory  anes- 
thesia. On  account  of  the  rich  anastomosis  of  the  terminal  branches 
of  the  trifacial  it  must  be  supplemented  by  a  circumferential  infiltra- 
tion of  the  operative  field.  There  is  considerable  advantage  in  the 
fact  that  such  a  complementary  injection  of  the  field  facilitates  opera- 
tion greatly  by  its  eff'ect  of  limiting  the  flow  of  blood. 

The  extraction  of  branches  of  the  trifacial  in  the  treatment  of  neu- 
ralgia can  only  be  carried  out  painlessly  when  they  are  anesthetized 
as  closely  as  possible  to  the  Gasserian  ganglion,  either  at  the  base  of 
the  skull  or  in  the  ganglion  itself.  For  the  first  branch,  on  account  of 
its  intracranial  course  and  its  close  relations  to  the  optic  nerve  and  the 
nerves  supplying  the  muscles  of  the  eye,  this  is  impossible;  for  the 
second,  which  passes  through  the  foramen  rotundum  in  the  greater 
w^ing  of  the  sphenoid  we  follow  the  method  of  injection  described  by 
]\Iatas;  the  third  root  is  met  in  the  vicinity  of  the  foramen  ovale,  or 
the  injection  is  made  in  its  two  branches,  the  inferior  dental  and  the 
lingual.  For  the  anesthetization  of  all  the  roots  at  once,  the  following 
method,  which  we  have  now  employed  for  the  extirpation  of  the 
Gasserian  ganglion  four  times,  msiy  be  used  with  advantage  to  replace 
general  anesthesia. 

In  a  forty-year-old  patient  the  second  branch  was  first  injected 
at  the  foramen  rotundum.  For  this  purpose  a  needle  10  cm.  long  was 
introduced  laterally  beneath  the  bony  prominence  which  marks  the 
junction  of  the  malar  bone  with  the  malar  process  of  the  upper  jaw 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION 


43 


(Fig.  1) .  The  needle  proceeded  inward  along  the  lateral  wall  of  the 
antrum  until  its  point,  at  a  depth  of  about  51/.  cm.,  impinged  upon 
the  external  plate  of  the  pterygoid  process.  It  was  then  withdrawn 
about  1  cm.,  the  portion  outside  the  cheek  strongly  depressed  and  its 
point  turned  further  toward  the  eye  until,  after  repeated  attempts,  at 


Fig.    1— local   AXESTHESL\    FOI!    KX  TlUrATIOX   OF  Till':  (iASSERL\N  GAXGLIOX. 

The  red  lines  give  tlie  direction  for  the  introduction  of  the  needle  for  injection  at  the 
foramen  rotunduni  and  the  foramen  ovale.  The  red  crosses  show  the  points  of  insertion  of 
the  needle  for  anesthetization  of  the  temporal  fossa  and  the  zygoma. 

a  depth  of  about  (ii  ..  cm.,  it  was  no  longer  in  contact  with  bone.  A 
skull  which  was  held  near  at  hand  clearly  showed  that  the  point  of  the 
needle  lay  in  the  sphenopalatine  fossa.  Upon  withdrawing  the  ])iston 
no  blood  was  aspirated,  and  .5  c.c.  of  1  •_>  per  cent,  novocain  solution 
could  be  injected  without  danger.  Since  the  patient  had  previously 
received  scopolaniin-niorphine.  he  did  not  feel  the  i)ain  in  the  teeth 
of  the  upper  jaw  which  is  taken  l)y  Schliisscr,  liraun  and  other 
authors  as  a  criterion  for  the  ])roper  |)osition  of  the  lu'cdje. 

In  order  to  anesthetize  the  third  root  hi  the  foramen  ovale  the 


44  ANESTHESIA 

mouth  was  opened  wide,  to  separate  the  coronoid  process  of  the 
lower  jaw  as  far  as  possible  from  the  zygoma.  Thereupon  the 
needle  was  introduced  through  the  skin  of  the  cheek  a  finger's  breadth 
below  the  middle  of  the  zygoma  just  above  the  tip  of  the  coronoid 
process,  inward  toward  the  base  of  the  skull  and  forward  toward  the 
pterygoid  process.  When  it  met  this  at  a  depth  of  5I/2  cm.  it  was 
Avithdrawn  1  cm.  or  more  and  its  direction  altered  by  lowering  the 
portion  outside  and  carrying  it  in  the  direction  of  the  mouth  until 
the  point  of  the  needle  glided  by  the  posterior  edge  of  the  external 
plate  of  the  pterygoid  process  and  passed  in  along  the  base  of  the 
skull  about  1  cm.  further.  Although  the  patient  even  now  had  no 
pain  in  the  teeth  of  the  lower  jaw,  a  comparison  with  the  skull  showed 
that  the  point  of  the  needle  must  lie  in  the  vicinity  of  the  foramen 
ovale.     At  this  point  also  5  c.c.  were  injected. 

Then  a  circumferential  injection  of  the  temporal  fossa  was  made. 
Through  each  of  five  points  of  insertion  the  needle  is  carried  in  A^arious 
directions  and  the  injection  made  above  and  below  the  temporal  muscle 
and  its  fascia.  Finallj"  at  the  anterior  and  posterior  ends  of  the  lower 
edge  of  the  zygoma  a  subfascial  and  subcutaneous  injection  of  about 
5  c.c.  was  made,  so  that  about  110  c.c.  of  the  solution  in  all  was 
employed. 

A  quarter  of  an  hour  after  the  injection  was  completed  the  cutting 
of  the  trap  door  in  the  bone  was  begun.  Incision  of  tlie  soft  parts  and 
bone  and  even  the  separation  of  the  dura  witli  the  Braatz  separator 
proceeded  without  expression  of  pain.  Only  when  the  freeing  of  the 
dura  from  the  base  of  the  skull  with  small  sponges  began  did  the  patient 
start  to  complain.  As  soon  as  the  second  and  third  roots  and  the  edge 
of  the  ganglion  were  exposed  about  eight  drops  were  injected  directly 
into  the  middle  of  the  ganglion  with  a  bent  needle,  so  that  it  was  filled 
up  like  a  bladder.  Immediately  thereupon  the  patient  fell  into  a  deep 
sleep.  The  removal  of  the  ganglion,  the  twisting  out  of  the  nerve 
trunks  and  the  sewing  down  of  the  trap  door  of  skin  and  bone  could 
then  be  carried  otit  completely  without  pain. 

Hartel*  has  demonstrated  a  method  of  anesthetizing  one  side  of  the 
face  by  a  single  injection  into  the  ganglion,  which  makes  injection  of 
the  various  facial  roots  unnecessary.  The  anesthesia  begins  immedi- 
ately. Through  the  cheek  a  long,  fine  needle  is  introduced  into  the 
third  division,  and  it  is  passed  within  its  sheath  through  the  foramen 
ovale  and  into  the  ganglion  itself.    In  this  way  the  third  branch  sei-ves 

*Zentral,  f.  Chir.  1912,  No.  21. 


F,X'rKE:\IITIES  45 

as  a  path  of  conduction  for  the  tieedlr  and  prevents  it  from  "^lichng 
off  and  piincturini>-  any  nciyhhoring  vesseL  The  introduction  is  made 
aI)out  '.i  cm.  external  to  the  aiif^le  of  tlie  mouth.  \N'itliout  injuring 
the  mucous  membrane  of  the  mouth,  the  needle  is  introduced  between 
the  lowei'  jaw  and  the  outer  wall  of  the  anlruin  as  far  as  the  infra- 
temporal fossa.  "Now  one  feels  his  way  backward,  observing  the 
following  important  points  concerning  the  direction  of  the  needle: 
Observed  exactly  from  in  front,  the  needle  should  point  to  the  pupil 
of  the  eye  of  the  same  side.  Seen  exactly  from  the  side  it  shovdd  point 
toward  the  articular  tubercle  of  the  zj'goma."*  As  soon  as  the  nerve 
trunk  is  met  by  the  point  of  the  needle,  the  patient  feels  pain  in  the 
lower  teeth.  In  this  way  one  recognizes  that  the  needle  is  in  the  right 
jjosition  so  that  the  needle  may  be  jjushed  along  further  until  pain 
is  felt  in  the  upper  teeth,  then  Hartel  injects  l/o  to  1  c.e.  of  a  2  per  cent, 
novocain-suprarenin  solution.  In  nine  cases  in  which  he  has  used  the 
method  he  has  obtained  complete  anesthesia. 

EXTREMITIES 

For  the  various  operations  on  the  neck,  thorax  and  abdomen  which 
may  be  carried  out  under  local  anesthesia  the  special  technique  Avill  be 
described  in  their  respective  chapters.  We  Avill  consider  here  only 
local  anesthesia  of  large  sections  of  the  body,  particularly  anesthesia 
of  the  entire  limbs  and  extremities. 

Kulenkampfft  found  that  in  oider  to  break  the  conductivity  of  all 
the  sensory  tracks  of  the  arm  the  proper  place  for  the  injection  is 
above  the  clavicle,  in  the  gap  between  the  scalenus  anticus  and  medius, 
where  the  brachial  plexus  runs  to  the  outside  of  the  subclavian  artery. 
The  artery  may  be  easily  recognized  by  its  pulsation,  and  the  clavicle 
is  likewise  readily  palpable.  The  brachial  plexus  lies  here  in  loo.se 
tissue,  which  is  particularly  suited  to  take  up  the  solution.  Ten  c.c.  of  a 
2  per  cent,  solution  arc  injected.  The  danger  of  injuring  the  sub- 
clavian artery  with  the  needle  is  slight ;  on  the  other  hand,  the  needle 
may  glide  by  the  plexus  and  come  u])  against  the  first  rib.  It  is, 
therefore,  advisable  to  inject  the  solution  oidy  after  the  patient  has  felt 
a  radiating  paresthesia  in  the  fingers,  which  signifies  that  the  needle 
is  in  contact  with  the  plexus. 

An  injection  wheal  having  been  made  in  the  skin  over  the  place 
decided  upon,  a  thin  needle  4>  cm.  long  is  inserted  in  the  direction  of 

•Hiirtel.  1.  c. 

fZentral.  f.  Chir.  1911,  No.  40. 


46  ANESTHESIA 

the  second  or  third  thoracic  spine,  that  is  to  say,  somewhat  medially 
and  posteriorly.  As  soon  as  the  fascia  is  penetrated  and  sensations 
arise  in  the  fingers,  the  syringe  is  emptied.  Since  the  arm  will  l)ecome 
hypereniic  in  a  short  time,  the  application  of  the  Ksmarch  method  of 
inducing  local  anemia  is  requisite.  Loss  of  sensibility  appears  in 
about  twenty  minutes  and  lasts  for  two  or  three  hours.  The  method 
of  Kulenkampff  has  been  tried  out  without  ill  effect  in  twenty-five 
cases.  In  our  experience,  in  the  care  of  cases  of  accidental  wounds  of 
the  hand,  the  procedure  has  several  times  proved  inadequate,  and  in 
o^iher  cases  the  anesthesia  did  not  appear  until  after  a  half  hour. 

The  anesthetization  of  large  sections  in  the  lower  extremities  is 
even  less  dependable;  a  complete  interruption  of  conduction  such  as 
that  in  the  upper  arm  is  not  possible  because  the  sensation  is  served  by 
four  nerve  trunks  which  lie  at  a  considerable  distance  from  each  other, 
the  obturator,  the  anterior  crural;  the  external  cutaneous  and  the  great 
sciatic.  Circular  subcutaneous  injections  about  the  extremities  induce 
an  anesthesia  of  the  skin  only,  which  suffices  for  skin-grafting. 
Nystriim*  states  that  the  external  cutaneous  nerve  Avhich  supplies  the 
surface  of  the  outer  part  of  the  upper  thigh  may  be  anesthetized 
through  a  subcutaneous  and  subfascial  injection  somewhat  below  the 
anterior  spine  of  the  ilium,  and  close  to  it.  Braun  anesthetized  the 
whole  foot  satisfactorily  by  injecting  the  subcutaneous  tissue  around 
the  leg  above  the  ankle,  for  the  terminal  filaments  of  the  external 
popliteal  (peroneal)  nerve  spread  subfascially  over  the  anterior  sur- 
face of  the  tibia  and  in  the  interosseous  space,  and  injecting  the  two 
branches  of  the  posterior  tibial  nerve  behind  under  the  Achilles  tendon 
and  near  its  medial  edge.  Anesthesia  appeared  in  twenty-five  minutes. 

In  order  to  carry  out  resections  and  amputations  on  the  peripheral 
portions  of  the  extremities  Biert  developed  a  form  of  anesthesia  which 
differs  from  the  foregoing.  The  field  of  operation  is  limited  by  two 
torniquets,  which  are  firmly  applied  above  and  below,  and  novocain, 
lo  per  cent,  in  physiological  salt  solution  without  the  addition  of  the 
suprarenin,  is  injected  with  considerable  force  into  the  veins.  The 
fluid  overcomes  the  valves  and  diffuses  through  the  capillaries  to  the 
terminal  filaments  of  the  nerves.  The  field  of  insensibility  Avhich  is 
obtained  through  this  direct  venous  anesthesia  spreads  as  the  fluid 
finds  its  way  into  the  larger  nerve  trunks,  which  Bier  has  already 
shown  with  indirect  venous  anesthesia. 

*Zentral.  f.  Chir.  1901,  Nr.  5. 

fVerhand.  li.  Dcutsch.  Gesselleschft.  f.  Chir.  190S. 


DIRECT  VENOUS  ANESTHESIA  47 

The  success  of  this  procedure  depends  upon  the  particular  care 
which  is  given  to  the  anemia  which  is  previously  induced  and  to  the 
venous  injection.  To  expel  the  blood  the  whole  extremity  is  held  up 
in  the  air  and  is  bound  from  toe  to  groin  with  a  soft  elastic  bandage, 
and  at  the  upper  end  of  the  operative  field  a  wide  tourniquet  is  laid 
on  to  cause  conijilete  circulatory  stasis.  The  expulsion  bandage  is 
then  taken  off,  and  at  the  lower  end  of  the  ojjerative  field  another 
tourniquet  is  applied.  Since  the  upper  tourniquet  cannot  be  borne  for 
any  length  of  time  on  account  of  the  pain  which  it  causes,  ^lomburg 
directs  that  after  the  anesthesia  has  begun  this  one  be  removed  after 
a  second  has  been  applied  within  the  insensitive  area  just  below  it. 

When  the  anemia  and  circulatory  stasis  is  complete  a  vein,  which 
has  been  marked  before  the  operation,  is  exposed  and  tied  off  prox- 
imally,  and  in  the  peripheral  end  a  cannula  with  a  rib  about  its  end 
is  tied  tight  enough  to  stand  considerable  pressure  without  leakage 
of  fluid.  It  is  then  connected  with  a  strong  and  tight  100  c.c.  syringe 
containing  the  novocain-salt  solution,  without  bubl)les.  The  injection 
should  be  made  slowly,  but  under  considerable  pressiu'e.  The  anes- 
thesia appears  between  the  two  tom-niquets  immediately  after  the  in- 
jection. The  amount  necessary  for  the  thigh  of  an  adult  is  75  c.c.  of 
the  1^  per  cent,  solution;  for  the  upper  arm.  .50  c.c. 

All  visible  vessels  must  be  seized  and  tied  at  the  end  of  the  operation. 
If  the  uj^per  tom-niquet  is  loosened  a  moment  so  that  blood  may  enter 
the  vessels,  and  then  drawn  tight  again,  it  will  enable  one  to  find  the 
lumen  of  the  larger  vessels  as  the  blood  spurts  out,  it  Avill  wash  ovit  the 
remnaTit  of  the  novocaiji  from  the  veins,  and  the  anesthesia,  nevertlie- 
less,  will  suffice  to  finish  the  operation.  The  instant  tliat  the  upper 
tourniquet  is  completelj''  removed  the  anesthesia  disappears. 


CHAPTER  3— ASEPSIS 

Drj'  asepsis  serves  best  to  promote  smooth  healing  of  wounds.  By 
asepsis  we  mean  practically  the  exercise  of  the  utmost  care  in  de- 
priving pathogenic  bacteria  of  access  to  the  wound,  without  injuring 
the  tissues  by  the  chemical  agents  which  are  employed  for  killing 
bacteria. 

Antisepsis  strove  to  attain  this  goal,  but  with  the  means  which  were 
at  its  disposal,  the  way  was  difficult.  The  principle  of  antiseptic 
wound  heahng  consisted  in  overcoming  bacteria  through  the  employ- 
ment of  chemical  poisons  (Lister's  carbolic  spray)  at  the  point  where 
they  were  already  in  contact  with  the  wound  or  were  about  to  be. 
Various  obsen^ers  have  demonstrated  the  inactivity  of  this  method 
toward  bacteria  in  an  infected  wound,  but  on  the  other  hand  have 
established  the  injurious  effects  which  chemical  agents  exercise  as  cell 
poisons.  Xow  efforts  are  made  to  keep  all  antiseptic  agents  from  the 
wound  and  to  free  so  far  as  possible  from  sources  of  infection  before- 
hand everything  which  comes  into  contact  directly  or  indirectly  with 
the  wound. 

The  ideal  of  absolute  asepsis  has  not  yet  been  wholly  realized;  it 
is  not  possible,  for  instance,  to  get  rid  of  antiseptic  poisons  altogether 
in  disinfection  of  the  skin.  And  even  after  strong  drugs  are  em- 
ployed in  the  preparation,  as  strong  as  the  skin  ^vill  stand,  it  is  not 
in  a  bacteriological  sense  absolutely  free  of  bacteria.  We  can 
succeed  in  reaching  a  state  of  absolute  freedom  from  bacteria  only 
with  instruments,  linen  and  dressing  material  which  have  been  steril- 
ized in  superheated  steam  or  in  boiling  water. 

Although  the  skin  remains,  from  the  purely  bacteriological  point 
of  view,  notwithstanding  our  efforts,  a  bacteria  carrier,  practical  ex- 
perience has  taught  us  that  the  removal  of  all  bacteria  carrying 
material  by  one  of  the  many  disuifectant  methods  suffices  to  overcome 
the  danger  of  infection  from  this  source.  Interference  with  healing  is 
to  be  laid  more  to  other  faidts.  which  are  the  more  numerous  the  more 
complicated  the  method  of  disinfection  is. 

Air-borne  infection  is  responsible  for  ti-ouble  still  less  frequently 
than  the  intelligently  disinfected  skin.  Infection  may  occm-  through 
bacteria-laden  dust,  or  through  drops  of  water  which  are  exhaled  in 

48 


AIR  BORNE  INFECTION  49 

forced  expiration,  coughin<>\  sneezin<j^  or  talking.  In  order  to  avoid 
this  possibility  many  surgeons  wear  a  face  mask  or  a  gauze  strip  tied 
over  the  mouth.  Some  have  given  up  this  ])ractice,  because  the  masks 
are  uncomfortable  on  the  face,  are  hot  and  heavy,  and  particularly 
because,  in  spite  of  the  mask,  wound  infection  has  still  occurred.  In 
quiet  breathing  no  considerable  danger  threatens  the  wound  from  the 
water  content  of  the  air,  but  if  one  is  in  the  habit  of  talking  a  great 
deal  during  the  operation,  or  if  one  wears  mustaches  or  a  beard,  one 
should  cover  the  mouth  while  operating. 

The  significance  of  dust  as  regards  wound  infection  cannot  be  over- 
looked. This  danger  may  be  lessened  if  everything  in  the  operating 
room  is  avoided  which  may  stir  it  up,  and  if  one  protects  the  open 
wound  by  a  jjad  of  gauze  so  that  dust  will  not  sink  into  it.  In  order 
to  prevent  the  dispersion  of  infective  material,  it  is  sufficient  to  wipe 
up  the  operating  room  with  a  damp  cloth.  In  hospitals  that  handle 
many  septic  cases  it  is  necessary  to  operate  upon  tlie  clean  and  the 
septic  cases  in  separate  rooms,  in  order  to  maintain  the  aseptic  room 
as  free  from  bacteria  as  possible.  The  filtration  of  air  going  to  the 
operating  room  is  of  illusory  benefit.  The  minor  significance  of  air 
infection  was  shown  in  the  time  of  strict  antisepsis  and  the  use  of  the 
carbolic  spray  was  given  up  early. 

A  strict  attainment  of  asepsis  is  the  easier  the  more  simply  and 
intelligently  it  is  carried  out.  Every  complication  in  methods  in- 
creases the  possibility  of  failure,  and  the  only  improvements  are  those 
which  increase  the  simplicity. 

DISINFECTION  OF  THE  SKIN 

In  order  to  destroy  the  bacteria  which  reside  in  the  skin  or  to  make 
them  harndess  to  the  wound  many  methods  have  been  recommended, 
but  they  all  possess  the  disadvantage  that  they  are  not  complete.  The 
ground  for  this  lies  in  the  anatomic  structure  of  the  skin,  which,  with 
its  surface  rich  in  hollows  and  ridges  and  with  its  innumerable 
glandular  orifices,  makes  it  very  difficult  for  aiitisej)tic  agents  to  reach 
the  bacteria.  They  may  be  removed  from  the  surface  through  me- 
chanical and  chemical  cleansing,  but  a  large  number  remain  in  the 
depths,  which  gradually  reach  the  surface  during  a  lengthy  opera- 
tion. 

Out  of  the  great  number  of  methods  which  have  been  employed, 
it  may  be  said  once  for  all  that  none  of  them  \vill  stand  strict  bacterio- 


50  ASEPSIS 

logical  investigation.  Without  going  into  the  methods  of  hand  dis- 
infection, we  shall  consider  here  only  that  which  has  served  ns  for 
several  years. 

DISINFECTION  OF  THE  HANDS 

The  hands  and  arms  as  far  as  the  elbow  are  washed  in  running  water 
for  a  quarter  of  an  hour  with  soap  and  brush,  and  cleansed  of  all  dirt. 
This  opens  up  and  cleanses  of  grease  the  sujjerficial  hornj"  layer  of 
the  skin,  and  prepares  it  for  the  penetration  of  the  antiseptic.  Un- 
irritating  alkali  soap  is  the  best  to  use  for  washing,  as  soft  soap  in  the 
long  run  is  not  well  borne  by  the  skin.  If  there  is  no  running  water 
at  hand,  the  washing  may  be  carried  out  with  standing  water  in  a 
basin,  which  must  be  frequently  changed.  The  temjierature  of  the 
Avater  should  be  as  high  as  possible,  because  hot  water  softens  the 
horny  laj^er  much  better  than  cold.  The  bacterial  content  of  running 
water  is  so  small  that  it  practically  may  not  be  considered.  For  this 
reason  hot  sterile  water  may  be  mixed  with  cold  running  water  with- 
out restriction. 

Mechanical  cleansing  of  the  skin  of  the  hands  consists  above  all  in 
scrubbing  them  continually  during  a  whole  quarter  of  an  hour.  The 
soap  must  be  rubbed  into  all  of  the  corners  and  wrinkles  of  the  fingers 
and  hand,  and  each  part  up  to  the  elbow  must  be  scrubbed  separately. 
Then  the  suds  are  washed  away  and  a  new  and  just  as  cai-eful  cleansing 
is  begun.  The  ordinary  cheap  hand  brush  is  suitable  for  tliis  mechani- 
cal cleansing.  Several  of  these  shoidd  be  sterilized  beforehand  by 
boilinff  with  water  in  a  vessel  without  the  addition  of  soda,  and  then 
placed  into  a  sterile  jar  containing  one  to  one  thousand  oxycyanate  of 
mercury.  Where  an  autoclave  is  at  hand  the  sterilization  of  the  brush 
may  be  carried  out  in  superheated  steam.  They  should  be  resterilized 
before  each  operation. 

The  soap  and  hot-water  cleansing  of  tlie  fingers  is  interrupted  once 
at  the  beginning  in  order  to  clean  the  nails.  The  cake  of  soap  during 
this  procedure  is  laid  upon  a  brush  which  is  turned  upside  down,  in 
order  not  to  bring  it  into  contact  with  the  sink.  Long  nails  make 
cleansing  diflficult,  and  they  should  be  trimmed  before  the  operation. 
Nail  shears  as  well  as  orange  stick  shoidd  l)e  sterilized  before  each 
operation.  In  using  the  nail  cleaner  one  should  not  be  so  strenuous 
as  to  undermine  the  nail  fold.  It  is  best  to  remove  only  with  the  blunt 
stick  the  dirt  and  skurf  which  has  been  softened  by  the  hot  soap  and 
water.     It  is  ^vTong  to  clean  the  nails  before  washing,  because  it  is 


DISINFECTION  OF  THE  HANDS  51 

only  through  washing  tlial  the  deep  layers  are  opened  up  and  the  bac- 
teria brought  to  the  surface. 

CHEMICAL  CLEANSING 

After  the  last  remnants  of  the  suds  have  been  washed  from  the 
elbow  and  arm  and  hand  under  the  faucet,  the  skin  is  scrubbed  in  a 
one-half  or  one  to  a  thousand  warm  solution  of  oxycyanate  of  mercury. 
The  soap  should  be  comjiletely  removed  from  the  skin,  because  the 
oxycyanate,  like  the  sublimate,  is  destroyed  by  soap.  In  order  to 
differentiate  the  oxycyanate  solution  from  water  and  other  fluids  it  is 
colored  with  a  few  drops  of  methylene  blue.  In  washing  as  well  as 
in  rinsing  off  the  arms  and  hands  care  must  be  taken  that  the  sleeves, 
which  have  been  rolled  up  to  the  middle  of  the  upper  arm,  do  not 
become  wet,  so  that  drops  may  run  down  the  arm  during  the  operation 
or  reach  the  wound  from  the  clothing.  Naturally  the  mercury  solu- 
tion can  only  destroy  the  organisms  which  are  on  the  surface  and 
possibly  those  also  which  lie  under  the  softened  uppermost  horny  layer. 
Since  the  germicidal  action  does  not  penetrate  into  the  ducts  of  the  sweat 
and  sebaceous  glands  and  the  rugte  of  the  skin,  we  repeat  the  washing 
in  oxycyanate  solution  several  times  during  the  course  of  the  opera- 
tion, in  order  to  render  innocuous  the  bacteria  which  come  to  the  sur- 
face as  the  result  of  the  skin  activity.  In  particular  we  should  be 
careful  that  no  blood  dries  upon  the  hands,  as  its  allnimen  is  precip- 
itated by  quicksilver,  and  when  it  has  once  dried  on  it  is  difficult  to 
remove.  The  solutions  in  the  basins  which  have  become  soiled  by 
blood  during  the  o])eration  should  be  immediately  renewed.  After 
washing,  the  skin  should  be  dried  off  with  a  sterile  sponge  in  order 
that  the  solution  does  not  drop  into  the  wound. 

Every  hand  which  takes  ])art  in  the  operation  should  be  subject  to 
this  same  strict  antiseptic  preparation. 

For  a  long  time  we  em])loycd  sul)limate  in  one-half  or  one  to  a 
thousand  solution,  but  since  it  is  not  well  l)orne  by  all  skins  we  have 
given  it  up.  The  bacterial  power  of  both  agents  is  slight,  but  the 
oxycyanate  does  not  exercise  so  intense  a  coagulating  effect  upon  the 
albumen  as  the  sublimate.  Anotlier  advantage  of  the  oxycyanate  is 
that  instruments  may  be  allowed  to  remain  for  a  considerable  time 
in  the  solution  without  being  corroded. 

FURTHER  RULES  FOR  A.SEPSIS  OF  THE  SKIN 

Alcohol  is  not  employed  by  us  either  as  a  disinfectant  or  to  de- 


52  ASEPSIS 

hydrate  the  skin ;  it  is  impossible  with  it  to  remove  the  fat.  Its  advan- 
tage of  fixing  the  bacteria  in  position  in  the  skin  so  that  they  will  not 
reach  the  surface  is  overcome  by  the  disadvantage  that  many  hands 
under  its  influence  become  cracked  and  chapped,  and  mechanical 
cleansing  with  soap  and  water  is  rendered  difficult.  Since  a  smooth, 
supple  skin  is  one  of  the  necessary  conditions  for  washing  and  disin- 
fection, we  strive  to  keep  the  hands  in  as  good  a  condition  as  possible. 
After  the  operation  is  over,  they  are  carefidly  washed  and  glycerine 
or  some  skin  lotion  is  applied.  This  is  not  washed  off  again,  but  is 
dried  on  a  towel.  The  glycerine  penetrates  into  the  horny  layer  and 
prevents,  on  account  of  its  hygroscopic  action,  drying  out  of  the  skin. 

As  a  further  precaution  against  carrying  of  bacteria  by  the  hands 
one  should  most  assiduously  avoid  all  contact  or  soiling  with  septic 
material.  This  may  be  done,  for  instance,  by  the  use  of  instruments  in 
changing  dressings,  and  by  wearing  rubber  gloves  in  all  septic  pro- 
cedures, as  well  as  in  making  certain  examinations.  Care  must  be 
exercised  wherever  possible  to  prevent  inadequate  skin  disinfection 
before  septic  procedures. 

Soiling  of  the  hands  during  operation  requires  a  complete  new  dis- 
infection with  soap  and  water,  as  well  as  sterilization  of  all  of  the 
instruments  which  have  been  used,  and  changing  the  linen  which  pro- 
tects the  operating  field.  The  washing  off  of  a  finger  alone  in  the 
oxycyanate  is  not  sufficient,  and  after  opening  the  intestine,  for  in- 
stance, or  a  septic  bladder  or  gall  bladder,  the  sewing  up  of  the 
abdominal  wall  should  be  completed  by  the  assistant  or  the  operation 
should  be  interrupted  until  the  hands  have  been  newly  cleansed. 

Since,  in  spite  of  all  precautions,  the  skin  of  the  fingers  remains  as 
the  most  important  source  of  wound  infection,  they  shoidd  not  be 
brought  into  contact  with  the  unprotected  wound  without  reason. 
Instruments  should  be  substituted  for  the  fingers  wherever  it  is  pos- 
sible, and  also  the  dressing  material  and  still  more  the  suture  material 
should  be  protected  from  the  contact  of  many  hands.  Joint  surfaces, 
muscle  wounds  and  free  plastic  flaps  as  well  as  the  meninges  are  par- 
ticularly susceptible  to  infection  through  direct  contact,  while  the 
peritoneum,  for  instance,  will  stand  a  good  deal. 

The  best  protection  of  the  skin  from  contact  with  septic  material 
is  the  impermeable  rubber  glove.  We  employ  it  for  the  protection 
of  our  own  skin  in  all  septic  operations  and  in  rectal  and  vaginal  exam- 
inations ;  in  clean  operations  many  continental  surgeons  depend  alone 
upon  the  disinfection  of  the  hands,  although  this  is  not  the  common 


RlinJER  GLOVES  53 

practice  in  America.  The  gloves  are  to  be  sterilized  before  usinjij  in 
superheated  steam  after  thev  have  been  powdered  with  talcum  inside 
and  out,  and  wrapped  in  gauze  or  placed  in  separate  pockets  in  a 
glove  holder,  in  order  that  their  surfaces  may  not  stick  together.  The 
hands  must  be  perfectly  dry  to  pull  the  gloves  on  readily.  For 
ordinary  examinations  and  wherever  the  autoclave  is  not  at  hand  they 
may  be  boiled  in  soda  bicarbonate  solution  and  then  put  on  after 
they  have  been  filled  with  oxycyanate.  They  lose  their  elasticity  rapidly 
with  boiling.  After  use  they  should  be  thoroughly  washed  and  cleaned 
of  all  dirt.  Small  tears  and  holes  may  be  mended  by  sticking  on  small 
pieces  from  an  old  glove  Avith  cement. 

Gloves  fit  the  fingers  and  hands  closely  and  comfortably  so  long  as 
they  are  new  and  still  elastic,  and  as  soon  as  one  becomes  used  to  them 
they  offer  no  hindrance,  excepting  to  a  certain  extent  in  the  palpation 
of  fine  differences;  for  instance,  as  in  testing  consistency.  Since  their 
smooth  surface  interferes  with  grasping  and  holding,  one  can  put  on 
over  them  a  sterile  cotton  glove  or  else  make  use  of  a  special  glove 
with  pebbled  surface.  Although  the  gloves  themselves  are  perfectly 
sterilizable,  they  do  not  give  complete  protection  to  the  wound  from 
the  bacteria  of  the  skin,  Avhich  stands  in  the  way  of  their  general 
employment,  particularly  for  aseptic  procedure.  A  small  tear  or  prick 
in  the  glove  suffices  to  l)ring  the  naked  skin  into  contact  with  the 
wound.  The  advantages  of  a  perfectly  sterilizal)le  skin  covering  are 
overcome  by  the  circumstance  that  bacteria  develop  under  the  glove 
as  actively  as  in  a  moist  chamber.  The  gloves  are  readily  torn  on  the 
corners  of  the  instruments,  on  needles  and  thread,  and  on  bony  splin- 
ters, and  frequently  the  damage  is  not  immediately  noticed.  Even 
though  all  who  favor  gloves  were  united  upon  the  ])rinciple  that  pre- 
vious disinfection  of  the  hands  should  never  be  slighted,  nevcrtlieless 
their  general  employment  may  increase  the  tendency  to  hurried  and 
careless  preparation.  In  this  ])ossibility  of  tearing  or  puncture  exists 
a  considerable  danger  to  the  patient,  and  if  a  tear  is  found  the  old 
gloves  are  to  be  removed,  the  hands  redisinfected  and  new  sterile  gloves 
applied. 

ASEPSIS  OF  THE   OPERATH'E  FIELD 

The  more  or  less  complicated  procedures  which  formerly  were  em- 
ployed for  sterilization  of  the  operative  field  have  been  discontiiuied 
by  most  surgeons  since  Grossich  confirmed  tincture  of  iodine  as  the 
simplest  and  surest  agent  conceivable.     Tinctin-e  of  iodine  was  used 


54  ASEPSIS 

before  his  day  for  bactericidal  and  dehydrating  properties,  in  tubercu- 
lous fistulfe,  for  instance,  but  to  Grossich  alone  must  be  given  the 
credit  of  the  general  introduction  of  the  use  of  tincture  of  iodine  for 
the  sterilization  of  the  operative  field.  Tlie  effect  of  the  tincture  de- 
pends upon  the  fact  that  the  bacteria  are  killed  on  the  surface  and 
are  fixed  in  the  depths  as  the  result  of  its  inhibition  by  the  crevices  of 
the  skin  and  the  intercellular  sj^aces.  Since  the  method  was  first 
published*  it  has  been  tried  in  many  clinics,  and  jjractically  without 
exception  the  reports  have  been  favorable.  Its  unconditional  safety 
has  given  it  preference  since  that  time  not  only  for  celiotomies,  joint 
and  skull  operations,  but  even  in  cases  where  the  skin  could  not  be 
satisfactorily  disinfected  by  the  methods  Avhich  were  earlier  employed. 
Thus  it  demonstrated  its  particular  advantages  in  laminectomies  in 
the  lower  section  of  the  spine  where  the  skin  for  a  long  time  had  been 
soiled  through  contact  with  m-ine  and  feces,  or  where  incisions  had  to 
be  made  in  a  close  proximity  to  a  bed  sore. 

Grossich  at  first  recommended  the  use  of  the  official  tincture  of 
iodine,  and  later  advised  against  the  unnecessary  modifications  of  his 
technique  which  were  being  constantly  proposed,  such  as  diluted  tinc- 
ture and  combinations  or  iodine  and  benzine.  It  is  of  great  importance 
in  order  to  get  the  full  activity  of  the  tincture  that  the  skin  does  not 
come  in  contact  beforehand  witli  any  sort  of  fluid,  but  that  the  tincture 
be  applied  to  a  dry  skin.  All  previous  cleansings  of  the  skin  with 
ether  or  benzine  should  be  omitted,  as  well  as  washing  with  soap  and 
water,  or  performed  at  a  considerable  interval  before  the  iodine  is 
applied,  because  all  fluids  make  their  way  into  the  glandular  openings 
and  intercellular  spaces  and  prevent  the  tincture  from  working. 
Shaving  and  the  cleansing  bath  should  be  given  on  the  day  preceding 
the  operation,  but  in  emergency  operations  the  bath  is  omitted  and 
the  patient  is  shaved  dry.  The  sujierfluity  of  the  removal  of  grease 
from  the  skin  and  its  mechanical  cleansing  has  often  been  showed  in 
the  treatment  of  accidental  wounds,  particularly  those  involving  tlie 
badly  soiled  skin  of  laborers. 

We  complete  the  sterilization  of  the  operative  field  in  one  applica- 
tion. A  sterile  sponge  which  is  held  by  a  sterile  clamp  is  satiu'ated 
with  tincture  of  iodine  and  this  is  apjjlied  over  a  wide  area.  Any 
excess  of  tincture  is  sopped  up  from  the  skin  by  means  of  another 
sterile  sponge.  Neither  before  the  incision  nor  after  the  operation 
is  iodine  reapplied.     On  the  contrary,  before  the  dressing  is  applied 

*Zentral.  f.  Chir.  1908,  Nr.  44. 


OPERATIVE  FIELD  55 

such  iodine  as  still  remains  on  the  skin  is  removed  by  a  sponge  which 
is  soaked  in  ether,  benzine  or  alcohol. 

We  have  never  seen  any  detrimental  results  when  the  (irossich  tech- 
nique is  strictly  followed.  It  appears  as  if  wound  healing  was  par- 
ticularly smooth  under  the  influence  of  the  tincture  of  iodine.  At 
any  rate  since  its  employment  stitch  abscesses  which  formerly  were 
an  infrequent  occurrence,  have  completely  vanished.  In  those  por- 
tions of  the  skin  which  are  natin-ally  damp,  and  where  the  evaporation 
is  hindered,  oi-  where  the  skin  has  previously  been  irritated  by  poul- 
tices or  adhesive  straps,  signs  of  irritation  may  sometimes  appear  in 
the  first  days  after  the  o{)eration.  Since  we  have  adopted  the 
practice  of  cleaning  the  skin  of  iodine  after  the  operation,  we  rarely 
see  either  this  mild  inflanunation  or  eczema.  The  removal  of  rem- 
nants of  iodine  should  be  done  with  particular  cai*e  from  the  scrotum, 
vulva  and  anus  as  well  as  upon  the  postei'ior  aspect  of  the  body  and 
in  deep  hollows  of  the  skin.  The  irritation  of  the  conjunctiva  and  the 
mucous  membranes  of  the  nose  by  the  free  iodine  may  sometimes  be 
disagreeable  for  those  engaged  in  the  operation. 

DISIXl-'ECTIOX   OF  THE   MUCOUS  MEMBRANES 

For  the  disinfection  of  mucous  membranes  tincture  of  iodine  cannot 
be  used,  because  they  are  normally  covered  with  a  moist  layer,  and 
moisture  interferes  with  the  antiseptic  action  of  the  tincture.  But 
wherever  the  epithelial  surface  of  the  mucous  membrane  is  destroyed 
and  ulcers  are  i)resent,  application  of  the  tincture  to  these  places  will 
prevent  infection  from  them  of  wounds  in  the  neighborhood. 

Absolute  sterilization  of  nmcous  membrane  cannot  be  obtained  with 
any  agent.  Practically  this  has  no  great  significance,  since  wounds 
in  the  mucous  surfaces  usually  heal  particularly  well.  Strong  anti- 
septic solutions  cannot  jjroperly  be  applied,  since  they  cause  in- 
flammatory irritative  symptoms  and  are  readily  absoi'bed.  In  opera- 
tions involving  the  nmcous  membrane  of  the  mouth  we  are  satisfied 
with  washing  it  out  repeatedly  the  day  before  operation  with  hydro- 
gen dioxid.  Just  preceding  the  operation  we  sponge  off  the  mucous 
siu-faces  with  -1  per  cent.  l)oric  acid  solution.  Tiie  vagina  similarly  is 
washed  out  the  day  before  operation  with  a  mild  antiseptic  solution, 
and  just  preceding  the  operation  it  is  douched  with  suds,  followed 
by  a  rinsing  with  boric  acid  solution,  lysol  or  alcohol.  ^Mucous  mem- 
branes of  the  stomach  or  intestines  which  have  been  opened  during  the 
course  of  an  operation  are  not  disinfected,  but  any  Idood  and  nuicus 


56  ASEPSIS 

is  wiped  up  with  dry  sponges.  Whatever  adheres  to  the  hue  of  union 
in  intestinal  anastomosis  after  suture  of  the  mucous  membrane  or 
serosa  is  carefully  removed  by  gauze  which  has  been  moistened  with 
physiological  salt  solution. 

STERILIZATION     OF     INSTRUMENTS,    DRESSINGS 
AND    SUTURE   MATERIAL 

The  siH'est  method  of  sterilizing  instruments  and  dressings  is  steam 
imder  pressure  or  boiling  water.  All  objects  which  are  not  destroyed 
or  rendered  useless  by  the  influence  of  heat  must,  therefore,  he  pre- 
pared by  this  method. 

STERILIZATION  OF  IXSTRUilENTS 

JNIetal  objects  should  be  boiled  on  account  of  the  simplicity  and 
greater  assurance  of  this  method.  To  prevent  rust,  soda  bicarbonate 
is  added  to  the  water;  a  handful  to  about  five  quarts  suffices  to  cover 
the  instruments  with  a  very  fine  precipitate.  After  the  operation,  the 
instruments  shoidd  be  laid  in  cold  soda  solution,  scrubbed  clean,  and 
rubbed  dry  with  a  towel.  The  soda  should  not  be  allowed  to  remain 
for  too  long  a  tune  upon  the  metal,  because  its  hygroscopic  action 
finally  causes  the  metal  to  rust.  The  addition  of  soft  soap  to  the  water 
will  make  it  easier  to  polish  off  the  cold  instrmiients.  Instruments 
should  always  be  put  away  clean  and  dry. 

Since  heat  radiates  the  most  rapidly  through  a  good  conductor,  the 
instruments  should  be  made  completely  of  metal  and  Avithout  wooden 
or  composite  handles.  Wood  splits  in  hot  water  and  the  heat  does 
not  penetrate  to  the  deeply  situated  bacteria.  So  far  as  possible  the 
instruments  should  be  smooth  and  polished  and  of  simple  mechanism. 

If  these  requirements  are  fulfilled,  it  is  sufficient  to  leave  the 
instruments  for  five  minutes  in  boiling  water.  In  order  to  make  assur- 
ance doubly  sure,  we  allow  oiu*  instruments  to  remain  ten  minutes 
in  water  which  is  boiling  hard.  In  the  sterilizer  they  lie  in  order 
upon  a  perforated  tray,  which  can  be  lifted  out  with  sterile  hooks. 
For  use  they  are  laid  upon  a  dry,  sterile  sheet  folded  several  times, 
or  there  should  be  a  thick  sterile  pad  next  the  table,  because  the 
moisture  through  capillary  attraction  sucks  up  bacteria  from  the 
lower  layers.  In  order  to  keep  the  table  covers  dry,  the  water  is 
allowed  to  drain  off  from  the  tray.  They  must  naturally  be  protected 
from  every  contact  with  unclean  objects.  The  instruments  are  used 
dry  and  should  not  be  kept  in  salt  solution,  lysol  or  any  other  anti- 


STERILIZATION  OF  INSTRUMENTS  57 

septic  medium.  They  may  be  washed  in  sterile  water  during  the 
operation  when  they  have  been  soiled  with  blood. 

Disinfection  of  instruments  in  antiseptic  solutions  has  been  given 
up,  ])ecause  it  is  not  sure,  and  because  remnants  of  the  antiseptic 
fluid  remain  upon  the  instruments,  and  so  come  in  contact  with  the 
wound  siu'face  and  through  irritation  interfere  with  wound  licaling. 
Polished  knives,  in  order  that  their  edges  do  not  suffer  from  boiling, 
may  be  laid  for  fifteen  minutes  in  70  per  cent,  alcohol;  we  prefer  that 
the  blade  be  wrapped  with  paper  or  laid  in  a  perforated  metal  rack  to 
protect  it  and  boiled  with  the  other  instruments.  Syringes  with  hard 
rubber  jjarts  or  leather  washers  ready  for  use  may  be  kejit  in  one  to 
two  thousand  oxycyanate  solution,  although  this  does  not  really  sterilize 
them;  glass  syringes,  and  also  those  with  metal  tops,  may  be  kept  in 
alcohol,  but  when  possible  they  should  be  sterilized  by  boiling  before 
use. 

Ordinarily  metal  and  glass  objects  may  be  boiled  together  in  soda 
solution;  the  boiling  of  rubber  drains  and  soft  rubber  catheters  should 
when  possible  be  carried  out  by  themselves,  for  the  metal  instruments 
are  attacked  by  the  sulphur  contained  in  rubber,  so  that  they  lack 
precision  in  closing.  Hard  rubber  catheters  and  bougies,  and  par- 
ticularly silk  lisle  catheters,  do  not  stand  hot  water.  They  may  be 
well  sterilized  in  the  autoclave,  but  like  gloves  they  must  be  kept 
from  coming  in  contact  Avith  each  other  by  being  wrapped  in  blotting 
paper.  But  to  be  preferred  is  boiling  in  a  saturated  aqueous  solution 
of  magnesium  sulphate,  in  concentrated  salt  solution,  or  in  a  60  per 
cent,  ammonium  sulphate  solution.  Several  forms  of  apparatus  have 
been  constructed  for  their  disinfection  in  formalin  vapor. 

STERIIJZATION   OF   nRESSIXfiS   AXn  I.INF.N 

All  linens  which  are  employed  in  the  oj^eration  may  be  sterilized 
just  as  assuredly  as  the  instruments.  Sheets  and  gowns,  sponges  and 
towels  are  done  up  in  packages  and  wrapped  separately  in  two  layers 
of  sheeting  and  sterilized  by  steam  under  pressure  foi-  twenty  to  thirty 
minutes.  This  time  is  reckoned  not  from  the  moment  when  the  pack- 
ages are  placed  in  the  autoclave,  but  from  the  time  the  thermometer 
reaches  120  C.  (248  F.).  By  this  time  the  air  has  been  forced  out 
of  the  chamber  and  steam  is  present  under  at  least  one  atmos])here 
(15  lbs.)  pressure.  In  order  that  the  steam  may  penetrate  to  all 
layers  of  their  contents,  the  ])ackages  should  be  piled  uj)  loosely  to- 
gether.    If  metal  containers  are  used  for  gauze,  sponges  and  dress- 


58  ASEPSIS 

ings,  they  should  be  open  during  the  steriHzation  and  should  be  shut 
only  after  they  have  been  taken  out  of  the  autoclave,  when  the  steriliza- 
tion is  over.  Through  their  lieat  the  remnant  of  steam  with  which 
they  are  impregnated  vaporizes  and  the  linen  and  dressing  material 
is  just  as  dry  to  use  as  the  instruments. 

All  sterilized  sheets,  gowns  and  dressings  remain  closed  until  just 
before  the  operation,  and  the  metal  drums  and  packages  are  opened 
just  before  use.  The  closed  packages  are  dated  with  a  rubber  stamp 
after  sterilization,  and  they  should  not  be  kept  for  a  long  time  with- 
out resterilizing,  since  the  moisture  in  the  air  and  the  fall  of  bacteria- 
laden  dust  upon  the  surfaces  may  result  in  penetration  into  the 
interior.  It  must  be  insisted  that  the  most  painstaking  regulations 
for  the  destruction  of  bacteria  remain  useless  if  in  putting  on  the  go^vn 
or  in  draping  the  operative  field  with  towels,  non-sterile  or  question- 
able objects  are  touched.  In  operating  only  that  narrowly  limited 
area  which  the  surgeon  himself  can  continually  oversee  should  be 
considered  as  unquestionably  sterile.  For  that  reason  it  is  well  never 
to  lay  instrimients  and  sponges  upon  the  sheet  which  drapes  the 
patient. 

IMPREGNATED  GAUZE 

Gauze  which  is  saturated  Avith  antiseptic  agents  requires  special 
preparation.  While  sublimate  gauze  and  materials  saturated  with 
carbolic  acid  and  other  agents  are  no  longer  used,  the  use  of  iodoform 
gauze  in  wounds  which  are  not  aseptic  has  continued.  It  is  employed 
to  assist  the  asepsis,  in  that  it  absorbs  the  secretions  and  prevents  them 
from  breaking  down,  even  if  retained  for  a  long  time.  The  unirri- 
tating  vioform  possesses  in  the  highest  degree  the  property  of  drying 
out  wound  cavities,  and  for  that  reason  we  employ  vioform  gauze  at 
times  to  shut  off  large  wound  cavities  or  bleeding  surfaces  and  protect 
them  against  the  entrance  of  bacteria.  To  iodoform  is  ascribed  a 
specific  influence  in  tuberculosis,  which  depends  essentially  upon  the 
effect  of  tlie  iodine.  In  the  destructive  processes  which  go  on  in  a 
secreting  wound,  the  iodoform  splits,  giving  off  free  iodine.  One 
must  always  be  on  the  lookout,  when  iodoform  is  employed,  for  its 
toxic  effects.  They  exhi])it  tliemselves  in  the  appearance  of  a  fire-red 
exanthem  with  numerous  blebs,  at  the  site  of  application  or  at  some 
distant  place,  or  even  over  the  entire  body,  accompanied  by  fever, 
headache,  and  in  particidarly  severe  cases  with  hemorrhagic  nephritis 
and  psj'chic  disturbances. 


ANTISEPTIC  GAUZE  59 

As  the  iodoform  in  itself  possesses  no  antiseptic  properties  and  may 
verj''  readily  carry  virulent  germs  into  the  wound,  the  gauze  which 
is  to  be  impregnated  must  be  previously  sterilized.  Tliis  jirocedure 
is  carried  out  in  the  following  maimer:  Ten  selvaged  l)aiidages  five 
yards  long  of  any  width  up  to  three  inches,  after  being  unrolled  and 
moistened  with  hot  water,  are  dii^jjed  in  the  following  solution: 

Iodoform 50. 

(ilyeerine 4.50. 

Alcohol,  96  per  cent .500. 

and  are  thoroughly  impregnated  with  it.  After  being  wrung  out  they 
are  hung  up  in  a  dark  room  to  dry  and  are  finally  cut  into  convenient 
lengths,  rolled  up  and  placed  in  a  covered  porcelain  jar  until  used. 
If  raw  gauze  or  unselvaged  bandage  is  used,  the  edges  must  be  folded 
in.  They  must  be  kept  protected  from  light  before  use,  since  the 
iodoform  will  otherwise  be  destroyed  and  turn  blue. 

To  make  vioform  gauze,  the  material,  loosely  rolled  up,  is  dijijied 
in  a  suspension  of  vioform  made  as  follows: 

Vioform 10.0 

Milk  sugar 10.0 

Glycerine 25.0 

Alcohol  (9G  per  cent.)  .      .      .      .  50.0 

Distilled  water 500.0 

The  gauze  is  allowed  to  dry  for  several  days  u])on  a  ])orcelain  plate, 
and  it  is  then  sterilized  in  the  autoclave.  In  sterilizing  it  should  not 
be  j)laced  in  metal  containers,  as  the  vioform  attacks  the  metal  and 
coloi's  it  black. 

STEKII.IZATIOX  OT  srTl'KE  MATKUIAL 

For  tying  and  sewing  up  we  recpiire  a  tenacious  thread  which  may 
be  com})letely  sterilized.  But  no  material  at  our  disposal,  whether 
absorbable  or  permanent,  fulfills  all  requirements  well.  Silk,  linen, 
silkworm  gut,  hoi'sehair  and  particularly  wire  may  be  freed  from 
bacteria  by  boiling  or  in  the  autoclave,  but  the  tics,  and  particularly 
the  contimious  sutures,  remain  as  foreign  bodies  in  the  tissues,  and 
do  not  always  heal  in  without  irritation,  particularly  if  the  knots  have 
been  tied  by  the  naked  finger.  On  the  other  hand,  the  absorbal)le 
catgut  cauiiot  l)c  used  after  this  form  of  safe  sterilization,  for  as  the 
result  of  heat  it  loses  its  tenacity  and  elasticity,  so  that  it  is  readily 


60  ASEPSIS 

broken.  In  order  to  free  catgut  of  bacteria  it  must  be  saturated  for  a 
long  time  with  antiseptic  agents,  the  remnants  of  which,  contrary  to 
the  rules  of  pure  asepsis,  must  be  shut  up  with  it  in  the  tissues.  INIore- 
over,  since  the  catgut  knots,  and  particularly  running  sutures,  do  not 
absorb  rapidly,  and  act  for  a  considerable  length  of  time  as  foreign 
bodies,  the  outlook  for  a  smooth  healing  in  of  the  chemical  saturated 
material  diminishes. 

Accordingly  the  quarrel  as  to  whether  silk  or  catgut  shall  be  pre- 
ferred for  buried  sutures  cannot  be  decided  off-hand.  But  the  idea 
that  stitch  abscesses  or  necrosis  of  tissue,  which  occasionallj'  but  not 
often  disturb  woimd  healing,  unexpectedly  and  unwelcomely,  depends 
on  uncleanliness  of  the  material  is  a  mistaken  one.  The  fault  lies  to  a 
far  greater  degree  in  the  insufficiency  or  inadequacy  of  the  skin  dis- 
infection, and  in  the  influence  of  the  sutures  as  foreign  bodies,  and  in 
the  tissue  irritation  from  antiseptic  solutions.  Bacteriological  tests 
of  suture  material  may  persistently  demonstrate  its  freedom  from 
bacteria.  It  appears  as  if  the  bacteria  which  are  rubbed  into  the 
material  by  the  skin  in  tying  the  knot  find  a  medium  which,  through 
the  tissue  reaction  to  the  foreign  bodies  and  the  irritating  effect  of 
antiseptics,  seems  to  be  particularly  fitted  for  their  development.  This 
is  the  only  explanation  that  can  be  offered  for  the  stitch  abscess  which 
first  develops  a  week  or  ten  days  and  sometimes  even  longer  after 
the  operation  in  a  wound  which  up  to  that  time  has  been  satisfactorily 
aseptic. 

EMPLOYMENT   OF   VARIOUS    SUTURE    MATERIALS 

Since  rapidly  absorbable  foreign  bodies,  if  they  only  remain  in  the 
tissue  with  as  little  irritation  as  possible,  form  assuredly  the  jjoorest 
culture  medium  for  the  bacteria  which  are  implanted  with  them,  we 
accordingly  recommend  for  deep  suture  and  for  tying  the  finer  sizes 
of  catgut.  For  instance,  for  mucous  membrane  and  wounds  of  muscle 
and  fascia,  No.  0  or  1 .  Only  for  the  peritoneum  and  for  stomach  and 
intestinal  mucous  membranes  are  running  sutiu'es  employed,  and 
everywhere  else  the  interrupted,  in  order  to  limit  as  far  as  possible 
necrosis  and  the  effect  of  a  foreign  body.  Silk  suture  material  should 
be  preferred  in  the  imiting  of  the  serous  coats  of  the  stomach,  in- 
testines and  bladder,  because  here  the  suture  is  not  intended  to  be 
readily  absorbed,  and  should  be  strong  enough  to  hold  under  consid- 
erable tension,  which  would  not  be  true  of  fine  catgut.  Upon  the  same 
ground  silk  must  be  given  the  preference  over  catgut  in  closing  hernial 


SUTURE  MATERIAL  61 

canals  in  tlie  radical  operati'>n  for  hernia,  and  kangaroo  tendon  pos- 
sesses advantages  over  catgut  for  this  purpose,  and  is  so  used  by  many 
surgeons.  Also  linen  which  has  been  treated  with  celloidin  (Pagen- 
stecher),  on  account  of  its  cheapness,  fineness,  strength  and  steriliza- 
bility,  is  excellently  adapted  for  these  sutures.  For  sewing  up  the 
skin  nothing  excels  the  readily  sterilizable  silkworm  gut,  or,  for  the 
face,  horsehair. 

To  unite  bones  or  to  close  hernial  and  other  openings  which  are 
under  strong  tension,  the  best  service  may  be  procured  from  the 
absorbable  and  safely  sterilizable  aluminum  bronze  wire.  The  un- 
irritative  healing  which  follows  the  use  of  this  material  practically 
without  exception  can  almost  entirely  be  referred  to  the  fact  that  the 
polislied  sin-face  of  the  thread  cannot  carry  bacteria.  And  no  doubt 
the  hands  also  have  less  occasion  to  touch  the  thread  and  to  wipe  off 
bacteria  in  holding  on  to  it  and  while  tying  the  knot,  as  on  account 
of  the  smoothness  and  stiffness  of  the  material  this  nnist  ordinarily 
be  done  with  instruments  or  gauze. 

STERILIZATION   OF  CATGUT 

In  the  preparation  of  catgut  so  far  as  possible  a  clean,  raw  product 
should  be  j^rovided  and  the  technique  carefully  followed.  Bacterio- 
logical examinations  show  that  pus  organisms,  tetanus  and  anthrax, 
which  in  previous  experience  might  be  met  with  in  raw  catgut,  are 
never  found  in  the  raw  material  prepared  according  to  Kuhn.  For 
use  the  catgut  is  sterilized  after  the  method  of  Claudius  in  an  iodine- 
potassium  iodide  solution  in  the  following  way:  In  a  sterile  vessel  the 
unrolled  catgut  is  covered  with  the  followhig  solution: 

Iodine  crystals 2  c.c. 

Potassium  iodide       ....  4  c.c. 

Distilled  water 1000  c.c. 

and  is  allowed  to  remain  for  twenty-four  hours.  For  size  No.  3  and 
all  larger  sizes,  which  we  personally  never  use,  the  treatment  must 
be  prolonged  for  twelve  hours  more.  After  this  time  is  over  the 
solution,  wliicli  is  sufficient  for  twenty-five  strands  five  yards  long,  is 
poured  off  and  replaced  by  SO  ])er  cent,  alcohol,  which  takes  up  the 
excess  of  iodine  from  the  catgut.  ^Vhen  the  alcohol  is  colored  dark 
it  is  renewed,  but  if  the  catgut  is  to  be  kept  for  a  long  time  it  should 
be  thinned  with  water.  When  tlie  strands  have  lain  in  the  alcohol  for 
some  time  they  are  removed  and  placed  dry  in  a  sterile  glass.    Catgut 


62  ASEPSIS 

thus  prepared  may  be  used,  Xo.  00  for  use  on  the  dura,  No.  0  for 
suturing  the  intestines  and  for  ties,  Xo.  1  for  larger  vessels  and  for 
sewing  up,  and  far  less  frequently  Xo.  2  or  3  if  the  tension  of  the 
tissues  demands  a  stronger  thread. 

Surgeons  who  wish  to  save  the  bother  of  preparing  their  ovn\  catgut 
and  who  appreciate  the  convenience  and  cleanliness  of  using  it  in  glass 
tubes  may  obtain  catgut  as  well  as  other  suture  material  prepared  in 
various  ways  all  ready  to  use.  There  are  many  excellent  brands  on 
the  market,  put  up  by  manufactin-ers  who  have  acquired  considerable 
rejiutation  for  a  sterile  product.  The  better  makers  have  a  competent 
bacteriologist  test  samples  from  each  batch  and  apjjrove  of  it  before 
it  is  sent  out.  Recently  in  the  United  States  the  method  of  preparing 
catgut  originated  by  Bartlett  of  St.  Louis,  or  some  modification 
thereof,  has  been  adopted  by  a  considerable  number  of  hospitals. 

STERILIZATIOX  OF  SILK  AND  LINEN 

While  in  the  sterilization  of  catgut  Ave  cannot  get  along  without 
antiseptics,  the  use  of  such  agents  is  unnecessary  in  the  sterilization  of 
silk.  Impregnation  with  salts  of  mercury  should  be  done  away  with, 
because  the  silk  may  be  sterilized  Avith  more  assurance  and  with  less 
injury  by  boiling  or  in  steam  under  pressure.  The  opinion  that  as  a 
result  of  impregnation  with  antiseptic  the  development  of  bacteria 
in  the  suture  hole  is  hindered  is  negatived  by  the  fact  that  the  antisep- 
tic, particularly  the  salts  of  merciuy,  goes  immediately  into  union  with 
the  albumen  of  the  cells,  and  bacteria  from  the  hand  may  remain  on 
the  threads  in  spite  of  the  antiseptic.  The  fact  that  coarse  silk  is  not 
readily  sterilized  and  may  retain  bacteria  within  itself  has  taught  us 
not  to  bury  thick  threads  in  the  tissue,  but  Avhere  a  continuovis  or 
interrupted  suture  is  necessary,  such  as  in  serous  suture  of  the  abdom- 
inal organs  or  in  closing  hernial  openings,  to  use  only  the  finest  sizes, 
Xo.  1  and  less  frequently  Xo.  2.  The  largest  size  used  for  skin  sutures 
is  Xo.  5,  and  only  for  the  Heidenhain  hemostatic  suture,  Avhich  will  be 
described  later,  do  we  employ  as  large  as  'Ko.  14,  since  we  ahvays  re- 
move it  after  the  skin  is  sutured. 

In  the  chapter  on  blood-vessel  surgery  we  will  take  up  the  question 
of  the  paraffin  silk  specially  prepared  for  this  purpose. 

In  order  to  carry  out  the  sterilization  economically,  the  silk  which 
is  needed  for  an  operation  is  rolled  upon  a  card  or  glass  bobbin  and 
sterilized  in  a  glass  vessel  in  the  autoclave.  As  soon  as  the  glass  is 
cold  the  silk  is  covered  Avith  80  per  cent,  alcohol,  in  Avhich  it  may  remain 


DRAriNT,  THE  PATIENT  63 

staiuling  for  any  length  of  time  necessai'y.  A  bobbin  which  had  once 
been  taken  out  of  the  vessel  is  not  replaced  until  resterilized  in  boiling 
water  (without  soda).  ^Nlany  surgeons  sinij)ly  boil  the  silk  with  the 
instruments.    Silk  loses  its  strength  if  boiled  too  long. 

Linen  is  sterilized  in  the  same  way  as  silk.  It  has  a  smoother  sur- 
face, but  is  a  little  less  strong  than  silk  and  possesses  the  advantage 
of  greater  economy.  It  is  not  fitted  for  impregnation  with  antiseptic 
agents. 


*e>^ 


FURTHER  ASEPTIC  REGULATIONS  DURING 

OPERATION 

DRAPING  THE  PATIENT 

When  all  preparations  are  ended  every  one  who  is  concerned  in  the 
operation  puts  on  a  sterile  gown.  This  should  be  buttoned  in  the  back 
and  closed  in  fi-ont,  to  cover  the  body.  The  gown  may  have  sleeves 
reaching  lielow  the  wrist,  the  ends  of  which  are  gathered  in  under  the 
gloves,  or  it  may  have  elbow  sleeves  only,  and  the  forearm  be  covered 
by  separate  close-fitting  half  sleeves,  which  are  pinned  on  by  the  nurse 
with  sterile  safety  pins.  The  operative  field  is  painted  with  tincture 
of  iodine  and  its  surroundings  are  covered  by  four  towels.  Only 
enough  space  is  allowed  to  remain  uncovered  as  suffices  for  the  length 
of  the  incision.  In  order  that  the  towels  be  not  shoved  about  over  the 
wound,  they  may  I)e  pinned  together,  or  fastened  to  the  skin  edges, 
with  Backhaus  clamps.  A  large  celiotomy  sheet  with  a  small  slit- 
like opening  may  be  used  to  cover  everything;  its  oidy  disadvantage 
is  that  if  an  unexpected  change  becomes  necessary  during  the  opera- 
tion it  cannot  be  removed  without  some  danger  to  the  asepsis.  In 
laying  on  the  towels  as  well  as  in  draA^'ing  on  the  goA\Tis  one  must 
carefully  observe  that  they  touch  nothing  which  is  not  sterile  and  so 
become  a  source  of  infection  to  the  wound. 

From  the  beginning  of  the  operation  only  the  region  which  is  under 
the  eye  of  the  surgeon  is  to  be  considered  sterile.  Places  at  any  dis- 
tance, even  when  they  are  covered  with  sterile  towels,  are  not  to  be 
considered  sterile.  It  cannot  l)e  completely  avoided,  liowever.  that  as 
the  operator  or  his  assistant  turns  aliout  to  reach  for  instruments  or 
for  other  purposes,  the  goM7i  will  come  in  contact  with  something 
which  is  not  completely  sterile  and  thus  indirectly  become  a  means  of 
infection.  When  any  break  has  ha])pened  in  techm'que,  even  when  it 
is  no  more  than  a  suspicion,  the  whole  procedure  should  be  repeated. 


64.  ASEPSIS 

otherwise  the  operating  room  personnel  will  become  careless  of  minute 
detail.  Towels  and  strips  which  have  become  soiled  during  an  in- 
testinal suture,  for  instance,  or  in  opening  up  an  unsterilized  area,  are 
removed  before  the  wound  is  sewed  up  or  before  further  clean  regions 
are  exposed,  and  replaced  by  clean  ones,  the  gloves  are  removed  and 
the  hands  are  again  carefully  scrubbed  in  soap  and  water  and  oxy- 
cyanate  solution,  and  the  instruments  are  newly  rinsed  and  disinfected 
for  the  rest  of  the  operation,  unless  a  new  kit  has  previously  been 
prepared. 

Following  the  rule  that  the  fewer  fingers  the  less  danger  of  infec- 
tion, the  number  of  assistants  during  an  operation  should  be  as  few 
as  possible.  One  assistant  who  renders  the  field  of  operation  ap- 
proachable by  means  of  retractors,  and  a  nurse  to  handle  the  instru- 
ments, are  sufficient  for  practically  all  major  operations.  Both  must 
wash  off  their  hands  in  oxycyanate  solution  from  time  to  time  as  well 
as  the  operator,  and  in  every  detail  carry  out  without  remission  the 
rules  of  asepsis. 

CARE  OF  THE  WOUND 

Since  with  all  our  precautions  we  cannot  succeed  with  certainty  in 
preventing  all  access  of  bacteria,  in  dressing  the  wound  we  attempt  to 
make  it  as  difficult  as  possible  for  the  bacteria  to  develop. 

Accordingly,  we  spare  the  wound  surface  of  all  contact  with  antisep- 
tics. But  if  antiseptics  are  present  for  the  purpose  of  destroying 
bacteria  upon  the  uninjured  surface  of  the  skin,  their  bactericidal 
action  in  an  open  wound  is  reversed  rather  than  otherwise.  For 
antiseptic  agents  work  upon  fresh  wound  surfaces  as  cell  poisons, 
which  stimulate  the  tissues  to  secrete  and  lead  to  inflammatory  clianges 
or  to  necrosis,  effects  which  prepare  a  favorable  cidture  medium  for 
the  development  of  bacteria.  For  that  reason  all  instruments  and 
materials  which  are  brought  into  contact  with  the  wound  should  be 
dry  and  aseptic  and  not  moist  and  covered  with  some  antiseptic  agent. 

DRAINAGE 

The  difficulty  of  the  proliferation  of  the  bacteria  will  be  increased 
if  all  the  fluid  which  is  secreted  in  a  wound  as  Avell  as  the  blood  which 
oozes  out  after  the  operation  can  find  an  unimpeded  exit.  A  wound 
which  glues  itself  together  rapidly  ofl^'ers  no  nutritive  material  either 
in  the  way  of  retained  secretion  or  hematoma.  Drainage  of  large 
woimds  and  the  most  careful  hemostasis  are  therefore  the  best  means 


DRAINAGE  AND  PACKING  65 

of  protection.  A  strong  transitory  compression  with  gauze  frequently 
suffices  for  a  complete  hemostasis.  In  order  to  pi-event  the  formation 
of  hematoma,  spurting  vessels  are  seized  and  tied.  Those  vessels 
which  come  to  view  in  making  the  incision  are  best  tied  off  before 
they  are  divided.  Where  blood  seejis  out  from  capillary  wounds  and 
in  places  where  numerous  lymph  vessels  are  cut  in  sewing  up,  we  leave 
an  opening  for  a  drainage  tube,  which  is  laid  to  the  deepest  part  of  the 
wound.  Sometimes  a  counter-incision  must  be  made  for  carrying  off 
the  secretions,  while  the  wound  itself  is  sewed  up  tight.  An  uneven 
wound  floor  which  cannot  be  smoothly  united  in  its  depths,  for  in- 
stance after  the  removal  of  a  tumor,  is  always  drained.  Two  or  three 
days  later,  or  as  soon  as  the  wound  suifaces  adhere  and  give  off  no 
more  secretion,  the  tube  can  be  removed. 

To  reinforce  hemostasis  in  oozing  surfaces  of  considerable  extent, 
and  to  suck  up  wound  secretion,  gauze  drainage  must  be  left  in 
occasionally.  For  this  purpose  we  employ,  especially  in  the  peritoneal 
canity,  folded  gauze  strips  a  yard  long,  of  which  one  end  is  conducted 
out  through  a  hole  in  the  suture  line.  Such  strips  have  the  advantage 
that  they  can  be  lost  only  through  gross  carelessness.  Plain  sterile 
gauze  is  used  for  general  purposes  and  for  the  drainage  of  the  peri- 
toneal cavity,  and  iodoform  gauze  is  used  only  for  the  drainage  of 
tuberculous  foci.  Vioform  gauze  has  the  advantage  over  sterile 
gauze  that  it  dries  out  large  cavities  more  effectively  without  irri- 
tating the  wound  or  exercising  a  toxic  effect.  It  may,  therefore,  be 
employed  in  extensive  and  strongly  secreting  wound  cavities,  for  in- 
stance after  extirpation  of  the  rectum,  and  in  small  but  deep  wounds 
where  one  is  not  sure  of  the  asepsis. 

If  packing  is  employed  to  control  venous  or  parenchymatous  oozing, 
sterile  strips  are  effective.  Such  oozing  ceases  from  the  pressiu'e  of 
the  gauze,  because  this  rapidly  adheres  to  the  vessel  wounds.  After 
five  days  at  the  latest  the  vessels  are  closed  through  a  ])ermanent 
thrombosis  and  the  stri])  can  then  be  removed,  although  it  may  remain 
longer  if  there  is  urgent  need.  Arterial  bleeding  should  not  be  con- 
trolled by  means  of  packing. 

Gauze  left  in  the  abdomen  should  always  be  wrapped  in  rubber 
dam  where  it  comes  through  the  wound  (cigarette  drain),  because 
skin  and  gauze  stick  together  ra])idly  and  in  that  way  the  secretion  is 
dammed  back.  For  the  gauze,  whether  it  is  plain  or  impregnated, 
is  always  a  source  of  irritation  to  the  cut  surface. 

Suprarenin  is  used  at  times  for  provisional  hemostasis.     To  allow 


66  ASEPSIS 

one  to  work  in  a  deep  h'ing  field  undisturbed  by  bleeding,  physio- 
logical salt  solution  is  employed,  to  100  parts  of  which  20  drops  of  the 
one  to  a  thousand  suprarenin  solution  are  added.  Gauze  sponges  or 
strips  are  soaked  in  this  solution.  For  hemostasis  over  deep  wounds 
where  the  vision  is  interfered  with  and  in  operations  upon  the  skull 
where  it  is  imijossible  to  tie  off  and  the  field  is  too  narrow  to  allow 
of  packing  Mith  gauze  strips,  sponges  soaked  with  suprarenin  maj^ 
be  used  to  advantage. 

For  the  drainage  of  wounds  of  the  sui^erficies,  such  as  amputation 
stumps  and  after  removal  of  the  breast,  and  particularly  where  the 
cosmetic  result  is  a  factor,  narrow  strips  of  rubber  dam  are  very 
eff'eetive.  They  do  not  adhere  to  the  woimd  edges,  nor  do  they 
promote  inspissation  of  the  secretions  and  in  that  way  plug  up  the 
incision.  For  this  reason  rubber  has  largely  supplanted  gauze  in 
septic  wounds. 

In  addition  to  hemostasis  and  to  the  carrying  off  of  wound  secre- 
tions, gauze  strips  serve  ijarticularly  well  also  in  shutting  off  a  clean 
field  from  infected  areas.  In  this  way  we  protect  the  free  peritoneal 
cavity,  the  meningeal  space,  the  pleural  and  other  cavities  from  infec- 
tion in  that  we  create  a  dam  around  about  the  infected  focus.  As  a 
result  of  the  irritation  which  the  protective  walling  off  exercises  upon 
the  tissues,  adhesions  form  which  at  first  are  loose,  but  later  make 
up  an  extensive  wall  against  the  penetration  of  infected  material. 
Gavize  impregnated  with  iodoform  irritates  the  tissues  more  to  the 
formation  of  adhesions  than  does  sterile  gauze. 

CARE  OF   THE   W^OUND  EDGES 

Next  in  importance  as  a  preventative  against  the  development  of 
bacteria  to  the  removal  of  wound  fluids  is  the  avoidance  of  every 
mechanical  injury.  A  smooth  division  of  the  tissues  with  a  sharp 
knife  is  better  as  regards  healing  than  dull  tearing  apart  or  bruising 
of  the  tissues  by  blunt  dissection.  The  sharply  cut  soft  parts  adhere 
again  rapidly.  In  irregular  wound  surfaces  with  hollows  and  pockets, 
foreign  bodies  and  necrotic  shreds,  this  adhesion  is  hindered  and  l)ac- 
teria  find  opportunity  to  develop  and  proliferate  in  the  exudate  which 
immediately  fills  the  dead  spaces.  The  incision  which  runs  in  the 
direction  of  the  fibres  is  the  most  advantageous  for  every  tissue.  In 
the  depths  tearing  and  bruising  of  the  tissues  may  be  avoided  if  one 
does  not  make  too  short  an  incision;  a  long  carefully  handled  wound 
heals  with  more  assurance  than  a  short  and  badly  damaged  incision. 


CARE  OF  THE  WOUND  67 

In  the  course  of  the  operation  everything  should  be  avoided  which 
might  increase  the  mechanical  irritation  of  the  wound.  Unnecessary 
contact  should  be  avoided  ])y  covering  the  wound  surfaces  with  gauze 
sponges.  Ties  shoidd  include  when  possible  only  the  bleeding  vessel, 
and  should  avoid  neighboring  tissues,  in  order  to  cause  no  necrosis 
in  the  woimd.  jNIass  ligatures,  if  possible,  should  be  done  away  with 
altogether.  In  the  same  waj'  in  aseptic  operations  the  thermocautery 
should  never  be  used  for  the  separation  of  tissues.  Bits  of  tissue 
lyhig  loose  in  the  wound,  such  as  splinters  of  bone  or  little  tabs  of 
fat,  shoidd  be  removed  before  sewing  up,  as  well  as  tabs  of  hanging 
muscle  and  fascia. 


CHAPTER  4— AFTER-TREAT:MEXT 

DRESSING 

At  the  close  of  the  operation  the  skin  in  the  neighborliood  of  the 
wound,  the  hne  of  suture  being  protected,  is  wiped  clean  of  remaining 
iodine  and  dried  blood  with  a  sponge  soaked  in  ether,  benzine  or 
alcohol. 

The  dressing  consists  of  sterile  gauze  next  the  skin,  covered  with 
absorbent  cotton  or  sheet  wadding.  The  gauze  when  laid  on  flat 
serves  as  a  compress,  or  if  opened  it  serves  to  absorb  any  blood  or 
wound  secretions,  as  well  as  the  moisture  of  tlie  skin.  The  cotton 
protects  the  wound  from  hai-mful  pressure,  reinforces  the  capillary 
action  of  the  gauze,  and,  so  long  as  it  remains  dry,  acts  as  a  filter 
against  bacteria  entering  from  without.  If  the  cotton  is  damp  it  loses 
these  properties  and  the  wound  dressing  must  be  changed.  If,  as  in 
certain  operations,  such  as  those  on  the  brain  and  spinal  cord  and 
on  the  chest  and  abdomen,  one  must  reckon  upon  an  early  and  marked 
infiltration  of  the  entire  dressing,  which  will  offer  favorable  circum- 
stances for  the  development  of  bacteria,  we  complete  the  dressing 
by  adding  an  outer  layer  of  sterilized  iodoform  gauze.  This  forms 
an  efficient  protection  against  the  danger  of  invasion  of  the  moist 
gauze  by  foreign  bacteria. 

Even  in  infected  wounds  the  lower  layer  of  the  dressing  should  con- 
sist of  plain  gauze,  in  order  that  no  irritation  of  the  skin  should  occur 
as  the  result  of  antiseptic  agents. 

The  dressing  is  fastened  on  with  a  gauze  bandage  or  by  adhesive 
straps.  Either  should  be  so  applied  that  the  dressing  material  and 
the  wound  edges  are  lightly  compressed  and  that  a  complete  occlusion 
of  the  wound  is  obtained.  For  wounds  which  secrete  freely,  and  which 
have  to  be  covered  with  a  thick  layer  of  dressing  material,  and  in 
places  where  the  hair  grows  rapidly,  appropriate  methods  nuist  be 
employed  for  keeping  on  the  bandage.  The  dressing  when  complete 
must  be  applied  so  as  to  allow  no  foreign  bodies,  for  instance,  rem- 
nants of  food,  or  even  the  hands  of  the  patient,  to  get  under  it  and 
reach  the  wound.  Wherever  the  dressing  stands  away  from  the  skin 
it  should  be  stuck  down  by  means  of  a  strip  of  zinc  oxide  adhesive 
plaster. 

68 


THE  FIRST  DRESSING  69 

Generally  speakiii<>',  wounds  on  the  linil),s  should  have  a  dressing 
applied  to  include  both  of  the  neighboring  joints.  In  wounds  of 
joints,  segments  of  the  limb  above  and  below  should  be  included 
in  the  bandage.  For  the  head  and  face  the  classical  methods  of 
bandaging  are  the  best.  Celiotomy  dressings  should  include  one  or 
both  thighs,  and  extensive  chest  and  shoulder  bandages  should 
include  the  head  and  neck.  In  applying  the  dressing  the  patient 
shoidd  assume  the  position  which  he  later  will  maintain  in  bed,  in 
order  that  the  edge  of  the  bandage  shall  not  cut  in  or  stand  away 
when  he  changes  his  ])osition. 

AVhere  it  is  available,  the  best  method  of  holding  on  dressing 
material  is  adhesive  plaster,  which  may  be  bought  in  every  width.  But 
plaster  strips  must  not  be  applied  overlapping  each  other  clapboard- 
wise,  but  between  them  small  spaces  must  be  left  in  order  that  the 
evaporation  of  the  skin  moisture  be  not  restricted.  Where  excessive 
and  ])ersistent  secretion  is  expected,  such  as  after  the  creation  of 
intestinal  or  bladder  fistuhe,  or  in  extensive  infected  wounds,  the 
dressing  should  be  held  on  by  means  of  a  swathe  or  many-tailed 
bandage,  undei-  which  the  dressmg  can  be  renewed  without  difficulty. 

To  hnmobilize  movable  portions  of  the  body,  it  suffices  to  incor- 
porate strips  of  s])lint  wood  in  the  dressing,  or  to  apply  a  splint. 
Where  wood  projects  and  touches  the  skin  it  should  be  carefully 
padded  with  cotton,  jjarticularly  when  bony  processes  lie  just  under 
the  skin.  For  the  limbs  one  may  use  any  sort  of  ready-made  splint 
of  wood,  wire  or  tin.  For  the  lower  extremity  the  Volkmann  T  splint 
is  an  advantageous  support.  When  anywhere  in  the  body  one  wishes 
to  guard  against  the  least  possible  motion,  a  Plaster  of  Paris  bandage 
is  applied  over  the  dressing.  To  facilitate  the  change  of  dressing  a 
window  is  cut  in  the  hardened  plaster  at  the  proper  place.  Fess 
resistant,  but  simpler  to  apply,  and  lighter  in  weight  than  the  plaster 
bandage,  are  the  starch  or  silicate  (water  glass)  bandages.  The 
impregnated  bandage  is  before  use  placed  in  water,  wrung  out  and 
applied  about  the  dressing.  Since  these  become  stiff  when  they  are 
dry,  their  edges  must  be  padded  to  prevent  them  from  cutting  into 
the  skin. 

CHANGINCJ  THE  DRESSING 

The  healing  of  an  aseptic  wound  follows,  as  a  rule,  under  a  single 
dressing.  The  dressing  is  first  changed  when  the  sutures  or  the  skin 
clamps  are  to  be  removed,  usually  after  a  week.     A  soft  sterile  pad 


70  after-treat:\ie\t 

or  an  ointment  dressing  is  then  applied  for  protection  over  the  fresh 
scar.  "\\^herever  the  Avound  is  ha])Ie  to  tension  or  where  sudden  pres- 
sure might  open  up  the  hne  of  suture,  some  or  all  of  the  stitches  may 
remain  without  danger  for  fourteen  days,  three  weeks  or  even  longer. 
An  abdominal  incision  may  thus  be  exposed  to  danger  in  attacks  of 
coughing,  vomiting  or  in  difficult  defecation.  The  sutures  remain 
throughout  this  period  without  arousing  any  reaction  or  they  grad- 
ually cut  their  way  through  the  skin,  but  usually  a  strong  epithelial 
scar  has  formed  by  this  time  between  the  stitch  holes.  A  mild  red- 
dening of  the  stitch  holes  does  not  demand  immediate  removal  of  the 
stitches,  since  after  the  passage  of  the  first  few  days  wound  infection 
does  not  arise  from  the  skin  or  from  the  open  stitch  holes,  under 
aseptic  conditions. 

The  appearance  of  fever  and  acute  pain  in  the  wound  in  the  first 
few  days  after  the  operation  signify  an  interference  with  healing, 
which  may  be  caused  through  infection  or  through  secondary  bleeding. 
If  only  insignificant  swelling  or  inflammation  of  the  stitch  holes  is 
evident,  it  is  sufficient  to  remove  one  or  another  suture  and  in  that 
way  allow  the  wound  edges  to  gap  without  danger  of  complete  sepa- 
ration. If  in  spite  of  this  the  temperature  ascends  and  general 
symptoms  as  well  as  the  appearance  of  the  wound  leads  one  to  make 
the  diagnosis  of  retained  secretion  or  infection  of  the  deeper  layers 
of  wound,  all  stitches  must  be  removed,  and  the  open  wound  must  be 
packed  lightly  in  all  of  its  recesses  with  rubber  dam.  The  temperature 
rise  from  an  iminfected  hematoma  disappears  twenty-four  hours  to 
forty-eight  hours  after  this  operation. 

The  time  to  dress  drained  wounds  depends  upon  whether  the  wound 
is  clean  or  infected.  Packing  which  serves  only  to  protect  a  large 
cavity  from  hematoma  or  infection  can  be  allowed  to  remain  for  a 
considerable  time,  particularly  if  it  is  impregnated  with  iodoform 
and  so  protects  the  absorbed  secretion  from  dissolution.  Bleeding 
from  venous  vessels  occurs,  as  a  rule,  immediately,  or  at  the  latest  not 
after  five  days,  so  that  packing  to  stop  the  vascidar  ooze  can  then  be 
removed.  When  a  drainage  wick  of  gauze  is  removed,  a  small  rubber 
dam  wick  should  be  left  in  the  wound  a  few  days  longer,  in  order 
to  anticipate  all  retention  of  wound  secretion.  Persistent  adhesions 
do  not  occiu'  until  after  a  considerable  time.  Accordingly,  in  order 
to  protect  against  the  extrusion  of  coils  of  intestine,  for  instance,  the 
packing  which  is  removed  at  the  first  dressing  must  be  replaced  by  a 
new  one.    If  a  strip  sticks  too  tightly  to  the  wound  edges,  it  may  be 


CHANGING  THE  DRESSING  71 

loosened  by  tlie  use  of  hydrogen  dioxid,  or  by  allowing  warm  boric 
acid  solution  to  trickle  upon  it. 

In  infected  wounds  and  those  which  secrete  freely,  the  dressin<r 
must  be  changed  early,  at  least  on  the  second  or  third  day  after  the 
operation.  Gauze  or  tube  drainage  even  in  this  length  of  time  may 
become  saturated  with  material  which  dries  and  inspissates,  the  dress- 
ing sticks  to  the  skin,  drainage  is  blocked,  and  retention  of  pus  is 
induced.  In  the  renewal  of  the  dressing  of  infected  wounds  the  same 
principles  applj'  as  at  the  first  dressing  after  the  operation.  Through 
adequate  drainage  the  wounds  must  be  held  open  until  the  pockets 
have  rid  tlienisclves  of  all  secretion,  necrotic  tabs  have  come  away  and 
fresh  red  granulations  appear. 

Protracted  healing  in  infected  womids  may  be  helped  out  by  stimu- 
lants such  as  balsam  of  Peru,  glycerine,  or  tincture  of  myrrh  in 
10  per  cent,  solution.  As  soon  as  an  infected  wound  cavity  appears 
clean,  it  may  be  closed  by  secondary  suture.  A  small  I'ubber  wick  is 
usually  left  in,  to  avoid  retention  of  secretions,  and  is  removed  in  a  few 
daj'^s  if  the  wound  surfaces  have  adhered  without  any  rise  in  tem- 
perature. As  soon  as  deep  wound  cavities,  after  several  changes  of 
drains,  have  been  converted  into  extensive  granulating  sm'faces,  scar 
formation  may  be  promoted  by  secondary  sutiu'e  after  mobilization 
of  the  wound  edges.  If  the  granulated  surface  appears  so  extensive 
that  a  secondary  suture  is  not  possible,  it  may  be  shrunk  gradually  by 
striping  it  with  the  silver  nitrate  pencil  from  the  skin  edge  outward. 
An  ointment  made  of  scarlet  red  serves  excellently  to  promote 
epithclialization.  The  best  means  to  hasten  scar  formation  with  the 
minimum  of  contraction  is  the  transplantation  of  epidermis  after  the 
method  of  Reverdin  or  Thiersch. 

SPECIAL  COMPLICATIONS 

CARDIAC   WEAKNESS 

Cardiac  weakness  after  the  operation  as  a  result  of  the  anesthesia 
or  the  loss  of  blood  is  combated  by  means  of  camjjhor,  caffeine,  or  the 
intravenous  injection  of  digalen.  A  subcutaneous  injection  of 
10  per  cent,  camphor  oil  may  be  repeated  as  often  as  the  heart  rc{[uires 
stimulation,  for  its  effect  rapidly  vanishes.  In  weak  patients  and 
those  who  have  lost  a  great  deal  of  blood,  injections  which  are  given 
one  after  the  other  are  usually  without  effect,  and  are  not  without 
danger.  If  the  heart  begins  to  flag,  the  caffeine  sodiobenzoate  in 
30  per  cent,  solution  gives  good  service;  an  injection  of  about  1  c.c. 


72  AFTER-TREATMENT 

may  be  repeated  every  hour.  In  addition  to  being  a  cardiac  stimulant, 
caffein  acts  also  as  a  stimulant  to  respiration  and  renal  activity. 
While  these  two  agents  have  an  immediate  effect,  which  rapidly  dis- 
appears, digalen  possesses  a  slower  but  more  persistent  action  upon 
the  heart  muscle.  It  may  ordinarily  be  administered  subcutaneously 
up  to  4  c.c.  per  day.  Given  intravenously,  it  works  more  rapidly  than 
by  subcutaneous  injection;  in  urgent  cases  we  repeat  an  injection  of 
1  c.c.  four  times  in  the  twenty-four  hours.  In  patients  with  arterio- 
sclerosis and  those  with  an  apojjlectic  tendency  care  must  be  exercised 
on  account  of  the  sudden  increase  in  blood  pressure  which  results. 

The  loss  of  a  large  amount  of  blood  during  the  operation  may 
be  compensated  for  by  a  subcutaneous  or  better  intravenous  infusion 
of  physiological  salt  solution,  which  may  be  repeated  several  times  in 
the  day.  In  threatening  cardiac  weakness  as  the  result  of  anemia  we 
add  twenty-five  drops  of  one  to  a  thousand  suprarenin  solution  to  the 
quart.  In  less  threatening  cases  the  subcutaneous  infusion  or  rectal 
instillation  by  the  drop  method  gives  good  service-  In  addition  to  the 
treatment  of  acute  hemorrhage,  a  washing  out  of  the  body  is  indi- 
cated in  peritoneal  sepsis  and  in  toxic  conditions;  moreover,  the  sub- 
cutaneous rectal  or  intravenous  infusion  is  the  only  means  of  satisfy- 
ing the  fluid  requirements  of  the  body  after  celiotomies,  when  the 
stomach  and  intestines  are  to  be  protected,  and  particularly  after 
operations  upon  these  organs. 

Further  means  to  combat  weakness  from  loss  of  blood  we  possess 
in  the  artificial  restriction  of  the  circulation.  For  this  purpose  we 
bind  the  legs  from  the  toes  to  the  groin  with  an  elastic  bandage  {auto- 
transfusion) .  At  the  same  time  the  foot  of  the  bed  is  raised  and  the 
head  is  lowered  to  prevent  a  long-continued  anemia  of  the  brain.  It 
is  very  important  in  these  conditions  of  weakness  that  care  should 
be  taken  to  keep  the  body  warm  by  means  of  hot  water  bags,  warmed 
or  electric  blankets  or  heating  pads,  used  carefully  on  account  of  the 
danger  of  burning. 

Although  the  transfusion  of  blood  from  one  man  to  another  or 
from  animals  to  man  was  given  up  several  times  in  the  past  five 
hundred  years  on  account  of  the  danger  which  was  connected  with  it, 
recently,  under  the  influence  of  Carrel  and  Hotz,  it  has  been  taken 
up  again  as  the  final  method  for  combating  a  sudden  and  serious  loss 
of  blood.  The  old  method  of  intravenous  infusion  of  defibrinated 
blood  has  been  replaced  by  direct  transfusion  between  two  persons. 
The  procedure  commonly  advocated  is  the  connection  of  the  radial 


SPECIAL  COMPLICATION'S  73 

artery  of  the  donor  to  the  median  cephahc  vein  of  the  recipient;  some 
men,  however,  favor  the  use  of  an  arm  vein  in  place  of  the  brachial 
artery  of  the  donor.  The  connection  is  made  by  direct  suture,  by 
means  of  a  cannuhi,  such  as  that  of  Crile,  of  Elsberg  or  of  Soresi, 
or  by  glass  tubes  or  containers  lined  with  paraffin. 

For  direct  transfusion  the  donor  should  l)c  a  young  and  healthy 
individual  preferably  from  the  same  family  as  the  patient,  to  avoid 
the  j)ossi])ility  of  intolerance  and  hemoglobinemia.  The  flow  should 
not  be  allowed  to  continue  more  than  thirty  or  forty  minutes;  the 
indication  for  disconnection  of  the  anastomosis  is  faintness  on  the 
part  of  the  donor  or  a  dro])  in  blood  pressure  from  125  mm.  to  100  mm. 

PAIX  IN  THE  AVOUXD 

Just  after  the  operation  we  frequentlj'  give  morphine  to  overcome 
pain  in  the  wound.  In  grown-ni^  persons  we  begin  with  an  injection 
of  1/4  grain,  in  order  to  obtain  a  definite  effect  at  once.  If  the  patient 
has  been  accustomed  to  morphine,  we  do  not  hesitate  to  give  consider- 
ably larger  doses,  with  the  purpose  of  overcoming  the  jiain  at  the 
beginning,  and  j)articularl}'  through  the  iirst  night.  If  morphine 
alone  causes  vomiting,  the  patient  may  get  morphine  with  atropin,  or 
pantopon,  the  latter  in  a  dose  double  that  of  mori)hine.  As  soon  as 
the  pain  has  disappeared,  we  cease  injections;  at  night  any  ordinary 
narcotic  is  given  when  necessary  to  induce  sleep.  For  the  psychic 
disturbances  which  not  infrequently  occur  in  nervous  patients,  in  the 
first  few  days,  the  bromids  are  of  service. 

I'ain  in  the  wound  and  the  restlessness  which  goes  with  it  should 
be  overcome  as  far  as  possible  after  the  operation,  because  it  may  have 
a  consi(lcral)le  influence  upon  the  healing.  A])art  from  the  admin- 
istration of  drugs,  much  may  be  done  to  lighten  distressing  conditions. 
All  disturbing  agents  should  be  kept  fi'oin  the  patient,  and  his  ])osition 
in  bed  may  be  rendered  more  comfortable  by  the  use  of  pillows,  foot 
supports  or  knee  rolls. 

THKo:\iBOsis,  embolus  and  pneumonia 

Since  physical  rest  has  much  significance  for  the  healing  of  wounds, 
and  early  movement  increases  the  danger  of  eml)olus,  we  keep  our 
patients  with  extensive  wounds  of  the  bones  or  soft  parts  of  the 
lower  extremity  in  bed  as  a  lule  several  weeks;  those  who  have  had 
celiotomies  and  operations  upon  the  brain  and  sjiinal  cord,  fourteen 
days;  after  procedures  on  the  upper  extremities,  the  thorax,  neck  and 


74  AFTER-TREATMENT 

face,  we  allow  patients  to  get  up  early,  sometimes  even  on  the  day 
after  operation.  Old  persons  with  bronchitis  or  a  tendency  to  pneu- 
monia and  cardiac  weakness  are  always  sat  up  on  the  day  following 
the  operation.  This  we  accomplish  by  the  use  of  a  back  supjjort  in 
bed  or  by  jjlacing  them  in  a  reclining  chair,  in  order  to  stimulate  them 
to  deep  breathing  and  to  better  ventilation  of  the  lungs. 

Ries  of  Chicago  and  Kiimmell  recommend  that  celiotomies  should 
regularly  be  allowed  to  get  up  the  day  after  operation,  and  they  see 
the  chief  recommendation  for  this  in  the  stimulation  of  circulation, 
decrease  in  the  formation  of  thrombi  and  danger  of  emoblism,  and  in 
the  favorable  effect  upon  the  general  well  being  of  the  patient.  In 
accordance  with  their  theory,  we  attempted  for  some  time  to  carrj'^  out 
early  rising  in  fresh  celiotomies,  but  in  a  large  proportion  of  cases 
we  found  stubborn  resistance.  And  in  spite  of  it  we  still  had  throm- 
bosis, and  several  patients  complained  greatly  in  the  second  or  third 
week  of  a  feeling  of  Aveakness  and  were  put  back  to  bed,  so  that  they 
received  no  benefit  as  regards  the  length  of  the  convalescence.  Never- 
theless, early  rising  after  operations  has  real  advantages  in  operative 
gjmecology,  since  the  proportion  of  thrombosis  and  embolism  after 
the  adoption  of  this  procediu'e  has  definitely  fallen.  The  advantages 
have  been  evident  also  in  a  great  number  of  appendix  patients,  who 
have  been  operated  on  during  the  acute  stage  or  in  the  interval.  The 
great  development  of  the  technique  of  this  operation,  particularly  the 
small  incision,  seems  to  make  a  two  weeks'  rest  in  bed  superfluous, 
since  the  scar  suffers  nothing  in  security  from  standing  up. 

The  threatened  danger  of  lung  inflammation  and  of  thrombosis  and 
embolism  can  be  met  with  almost  the  same  advantage  by  the  employ- 
ment of  less  radical  means.  "Weak  and  elderly  patients  are  assisted 
every  day  in  ventilating  the  air  passages.  Some  form  of  respiratory 
gymnastics  not  only  prevents  the  alveoli  from  sticking  together,  but 
also  markedly  stimidates  the  circulation  in  the  lungs.  In  the  same  way 
celiotomy  patients  should  move  their  legs  early.  Henle  advises  that 
"taking  a  walk"  in  bed  should  be  reinforced  by  massage  of  the  lower 
legs  beginning  the  very  first  day,  which  instruction  we  have  prac- 
tically always  followed  in  women  and  old  persons. 

GASTRIC   AND   INTESTINAL  DISTURBANCES 

Disturbances  of  the  gastro-intestinal  track  oftentimes  cause  ex- 
treme inconvenience  in  convalescence.  Vomiting  after  the  anesthesia 
has  become  less  frequent  with  expert  etherization,  but  has  not  dis- 


GASTROINTESTINAL  DISTURBANCES  75 

appeared;  usually  it  does  not  begiu  until  after  twenty-four  hours. 
The  best  way  to  overcome  recurring  attacks  of  nausea  consists  in 
absolute  denial  of  nourishment  and  fluid.  The  torturing  thirst  may 
be  assuaged  by  moistening  the  lips  and  tongue,  washing  out  the  mouth, 
allowing  pills  of  ice  with  or  Avithout  peppermint  to  melt  in  the  mouth, 
or  the  administration  of  cold  tea  or  coffee  by  the  teaspoonful  or  by 
subcutaneous  infusion.  Of  considerable  help  in  this  regard  is  the 
rectal  injection  of  a  half-pint  of  hike-warm  watei-  by  tlie  droiJ  method. 
to  be  repeated  several  times  in  the  day.  Xurslings  and  young  chil- 
dren, on  the  other  hand,  receive  the  bottle  immediately  after  the  end 
of  anesthesia.  Since  the  appetite  of  the  operative  patient  usually 
disappears,  it  is  best  not  to  off'er  solid  food  in  the  first  days  after 
the  operation.  But  an  exception  to  this  is  made  in  children;  if  they 
have  not  vomited,  we  give  them  solid  food  early.  After  chloroform 
anesthesia  in  particular  in  adults  it  is  not  unusual  to  see  catarrhal 
conditions  of  the  stomach  as  the  result  of  too  early  attempts  at  feed- 
ing. If  one  does  not  succeed  forthwith  in  overcoming  these  disturb- 
ances by  a  strongly  restricted  diet,  there  may  result  a  long-continued 
under-nourishment  with  loss  of  strength. 

ARTIFICIAL  FEEDING 

In  case  of  necessity  we  try  to  supply  nourishment  through  the 
rectum  by  means  of  nutritive  enemas.  It  is  not  possible  for  any 
length  of  time  to  induce  the  absorjition  of  a  sufficient  amount  of 
albumin  or  car])ohydrates  even  to  maintain  the  existing  state  of 
nourishment,  and  in  addition  frequently,  after  a  short  period,  a 
mucous  colitis  occiu's.  Ewald  recommends  the  following  nutritive 
enema:  4  drams  of  grape  sugar,  two  or  three  eggs,  as  much  as  can 
be  taken  up  on  the  point  of  a  knife  of  malted  milk  or  some  similar 
prepared  food,  one  wine  glass  of  red  wine,  and  half  a  glass  of  water 
or  milk.  This  mixture  should  be  allowed  to  run  into  the  upper  rectum 
at  the  temperature  of  the  bodj'.  In  the  morning  a  cleansing  enema 
must  precede  the  nutritive  enema.  In  order  to  avoid  causing  irrita- 
tion of  tile  lower  segment  of  the  colon  when  the  eiieiiias  have  to  be 
repeated  for  any  length  of  time,  fifteen  drops  of  tincture  of  opium 
are  added. 

Du  ]Mesnil  de  Rochemont  attempted  to  introduce  nourishment  by 
means  of  the  subcutaneous  injection  of  sterile  oil.  He  injected  up  to 
two  ounces  and  never  saw  any  injury  at  the  site  of  injection.  Fried- 
rich  also  injected  from  one  to  three  ounces  of  sterile  oil  slowly  under 


76  APTER-TREATMENT 

the  skin,  giving  twice  a  day  as  an  auxiliary  grape  sugar-salt  solution 
in  which  the  sterilizable  albumin  of  Siegfried,  pepsinfibrinpeptone, 
was  dissolved.  He  reconunends  the  following:  In  the  morning, 
l/o  dram  salt,  10  drams  grape  sugar  and  4  drams  albumin  in  1  quart 
of  water,  in  the  evening  the  same  with  half  the  quantity  of  the  albumin 
preparation. 

INSTITUTION   OF   PERISTALSIS 

The  patient  may  experience  severe  annoyance  as  a  result  of  per- 
sistent interference  with  intestinal  peristalsis.  This  is  particularly 
the  case  after  celiotomies  and  procedures  on  the  spinal  cord.  If  the 
difficulty  is  the  result  of  an  inflation  of  the  large  colon,  the  introduc- 
tion of  a  rectal  tube  and  the  passing  off  of  the  gas  will  usually  suffice 
to  give  relief.  Later,  peppermint  tea  will  oftentimes  prove  of  service. 
If  the  bowels  have  not  moved  spontaneously  on  the  second  day  after 
the  operation,  they  must  be  cared  for  by  enemas  or  cathartics.  JNIost 
patients  as  a  result  of  constipation  complain  of  headache,  loss  of 
appetite  and  loss  of  sleep,  none  of  which  serve  in  the  least  to  promote 
healing.  The  best  agent  to  induce  defecation  is  castor  oil,  but  one 
may  choose  between  salts  and  cascara  on  the  one  hand  and  enemas  of 
water,  glycerine  or  oil  on  the  other.  About  three  oimces  each  of 
honey  or  molasses  and  milk  makes  an  excellent  and  unirritating 
enema. 

In  complete  paresis  of  the  intestine  such  as  occurs  as  the  result 
of  a  purulent  peritonitis  or  after  severe  intraperitoneal  hemorrhage, 
results  may  frequently  be  obtained  bj"^  a  subcutaneous  injection  of 
1/64  grain  phi/sostigmine  sa'ic//!ate.  If  no  result  is  obtained  in  a 
quarter  of  an  hour  the  injection  must  be  repeated,  but  when  this  agent 
is  employed  one  must  be  on  the  watch  for  the  possibility  of  cardiac 
collapse. 

One  may  employ  with  some  assurance  the  organic  preparation  in- 
troduced by  Ziilzer,  hormonal,  M'hich  is  injected  intravenously  in  a 
dose  of  4  to  6  drams.  While  it  is  acting,  the  administration  of  mor- 
phine should  be  avoided,  for  it  interferes  with  the  specific  effect  of 
the  hormonal.  As  a  lubricator,  castor  oil  is  given  after  the  injection. 
The  action  of  hormonal,  in  contra-distinction  to  physostigmin,  is  a 
physiological  one;  it  gives  rise  to  a  peristaltic  wave  without  spasm  and 
its  influence  is  long  continued.  In  case  of  threatening  acute  intestinal 
paresis,  we  have  had  favorable  results  with  it  in  the  majority  of  cases; 
we  have  never  observed  injurious  effects  of  any  account. 


SPECIAL  COAIPTJCATIONS  77 

DISTURBANCES  OF  THE  BLADDER 

Retention  of  urine  after  operation  is  observed  less  frequently  than 
interference  with  intestinal  activity.  The  chief  cause  of  this  disturl)- 
anee  lies  in  the  fear  of  ])ain  which,  particularly  after  celiotomies  and 
gynecological  operations  in  women,  is  connected  with  the  evacuation 
of  urine.  After  the  radical  ojieration  for  hernia,  hemorrhoids  and  in 
some  degree  after  ])rocedures  on  the  brain  and  spinal  cord,  weakness 
or  paresis  of  the  bladder  may  be  mistaken  for  hematoma,  or  intestinal 
paresis  from  jjeritonitis. 

If  urination  does  not  occur  spontaneously  one  may  first  make  use 
of  ordinary  means  of  assistance,  such  as  hot  towels  or  hot  water  bags 
laid  on  over  the  region  of  the  bladder,  or  the  patient,  if  permissible, 
may  be  lifted  into  a  sitting  posture  or  allowed  to  stand  up.  These 
methods  are  at  least  less  dangerous  than  catheterization,  for  no  matter 
with  what  cleanliness  it  is  carried  out,  if  frequently  repeated  it  readily 
residts  in  a  cystitis.  Women  are  apt  to  become  accustomed  to  cathe- 
terization. Ordinarily  we  wait  before  trying  this  j)rocedure  until 
twentj'-four  hours  have  passed  after  the  operation. 


PART  II.  SURGERY  OF  THE  HEAD 

CHAPTER  5— TREATMENT  OF  WOUNDS  OF 

THE  HEAD 

WOUNDS  OK  THE   SOFT   PARTS 

All  wounds  of  the  soft  parts  on  the  head  may  be  considered  infected 
unless  they  have  been  received  under  aseptic  circiunstances.  This 
holds  particularly  for  wounds  received  from  accidental  injuries.  On 
the  scalp  they  require  particular  care  in  handling-,  because  wound 
infection  and  its  developments  involve  a  considerable  danger  not  only 
for  the  coverings  of  the  skull,  l)ut  also  for  the  brain  and  its  envelop. 
Favorable  opportunity  exists  in  the  richly  developed  blood  and  lymph 
vessels  which  ])ind  together  the  soft  Y>arts  and  the  bone  for  sources 
of  inllanimation  to  pass  from  without  inward.  Purulent  meningitis 
and  inflammation  of  the  brain  may  be  the  fatal  result  of  a  su2:)erficial 
infection. 

For  this  reason  fresh  accidental  M-ounds  of  the  head  of  any  extent 
should  not,  as  a  rule,  be  immediately  sewed  up,  but  should  be  treated 
openly.  First  the  surroundings  of  the  wound  over  a  considerable 
area  are  dry  shaved  and  painted  with  benzine  followed  by  tinctiu'e  of 
iodine,  or  with  iodine  alone,  then  the  torn  tissues  are  freed  of  dirt 
and  blood  clots  with  sterile  forceps  and  gauze  and  every  spurting 
vessel  is  tied.  In  order,  so  far  as  possible,  to  transform  the  whole 
wound  into  a  smooth-walled  cavity,  cruslied  portions  of  the  wound, 
edges  and  tabs  of  tissue,  are  removed  by  knife  and  scissors,  and  when 
necessary  tlie  external  skin  womid  is  eidarged.  Bridges  of  tissue 
which  separate  small  ])ockets  from  each  other  are  s])lil.  and  linally  the 
wound  cavity  is  packed  in  all  of  its  recesses  with  sterile  iodoform 
gauze. 

In  the  open  treatment  retention  of  blood  and  of  wound  secretions 
are  diminished,  and  in  that  way  the  danger  that  bacteria  find  favor- 
able conditions  for  forcing  their  way  into  the  depths  is  lessened.  If 
after  three  days  the  wound  surfaces  show  no  evidences  of  infection, 
the  packing  is  removed  and  the  wound  sewed  uj). 

Sometimes  exception  must  be  made  to  this  i)rinci])lc  of  the  open 
treatment  of  wounds  of  the  soft  parts  on  the  head.    If  as  the  result  of 


80  TREATMENT  OF  WOUNDS  OF  THE  HEAD 

powerful  trauma  in  a  tangental  direction  a  considerable  flap  of  skin 
is  torn  from  the  cranium,  this  must  be  replaced  on  account  of  the 
danger  of  necrosis  of  the  exposed  bone,  and  held  in  its  original  position 
by  several  stitches.  In  the  deepest  point  of  the  wound  pocket  a  drain- 
age tube  is  placed  and  sewed  in,  to  carry  off  wound  secretion  and 
blood.  A  longitudinal  incision  made  at  the  root  of  the  flap  ordinarily 
does  not  endanger  its  nutrition.  The  drainage  lessens  the  danger 
of  infection  since,  as  a  result,  tlie  wound  surfaces  remain  dry  and 
rapidly  adhere  to  each  other. 

Primary  closure  of  wounds  of  the  face  may  be  requisite  if 
cosmetic  results  are  to  be  considered,  for  with  secondary  suture  one 
never  obtains  so  fine  a  scar  as  with  primary  suture.  But  freshly 
sutured  wounds  contain  within  their  depths  hidden  sources  of  infec- 
tion. Therefore,  as  soon  as  signs  of  inflammation  appear  in  any 
sutured  wound,  stitches  must  be  removed  and  the  wound  opened  up. 

TREATMENT    OF    COMPOUND    FRACTURES    OF    THE    SKULL 

The  treatment  of  compound  fractures  of  the  skull  is  carried  out  on 
similar  jirinciples.  No  matter  what  the  origin  of  the  wound,  one  can 
never  determine  whether  or  not  it  is  infected,  and  even  though  the 
majority  of  compound  fractures  of  the  skull  heal  without  difficulty, 
nevertheless,  this  always  remains  an  insecin-e  probal)ility.  The  usual 
treatment  is  limited  to  cleaning  up  and  disinfecting  tlie  surroundings, 
applying  a  sterile  dressing,  and  waiting.  Without  doubt  this  method 
of  procedure  in  the  majority  of  cases  gives  good  results,  but  one 
should  never  judge  without  a  close  examination  of  the  wound  whether 
matter  has  been  forced  in  deep  which  may  lead  to  infection  of  the 
wound. 

For  example,  a  young  man  of  twenty-one  years  was  brought  into 
the  hospital  foin-  days  after  an  apparently  slight  wound  of  the  scalp, 
which  had  been  treated  in  the  above  manner;  he  presented  definite 
symptoms  of  meningitis  and  after  a  few  days  died.  Under  the  edges 
of  the  skin  woimd,  which  had  already  adhered,  was  found  a  fissure 
fracture  of  the  parietal  bone,  a  slight  splintering  of  the  lamina  vitrea 
and  an  extensive  tear  in  the  dura;  on  the  surface  of  the  crushed  brain 
substance  were  found  several  hairs.  Xo  symptoms  referable  to  the 
cortex  were  aroused  by  the  tramna,  which  in  an  injury  of  the  right 
parietal  lobe,  a  mute  region,  is  not  to  be  wondered  at.  One  such 
unfavorable  result  counterbalances  a  hundred  good  ones,  when  one 
considers  that  this  patient  might  have  been  saved  by  a  slight  procedure 


COMPOUND  FRACTURE  OF  THE  SKULL  81 

carried  nut  immediately  after  the  injury.  If  there  is  the  least  sus- 
picion that  the  scalp  wound  lias  been  contaminated  by  septic  material, 
it  should  under  every  circumstance  be  opened  up  wide.  One  should 
not  stop  even  at  trephining. 

In  addition  to  the  danger  of  infection,  one  may  often  look  for  later 
disturbances  on  the  part  of  the  brain  from  a  s^jlintering  of  the  internal 
table,  wliich  occurs  with  the  fracture.  In  irrcsjxinsive  regions,  which 
taken  altogether  make  up  tlie  largest  part  of  the  superficial  area  of  the 
brain,  such  a  splinter,  even  if  it  perforated  the  dura  mater,  might  lie  for 
some  time  without  causing  irritation,  and  only  arouse  symptoms  after 
the  course  of  weeks,  months  or  years.  Sucli  splinters  may,  as  experi- 
ence has  taught  us,  heal  in  and  smooth  over  without  causing  ej)ilepsy; 
and  moreover,  this  is  not  the  only  cause  of  this  brain  atlliction;  it 
may  come  also  as  the  result  of  a  severe  shaking  up  or  local  contusion 
of  the  brain  after  uncomplicated  fractures.  But  in  open  fractures 
the  possibility  of  its  occurring  must  always  be  considered  in  addition 
to  the  danger  of  infection. 

The  following  represents  our  experience  in  a  similar  case: 
A  thirty-seven-year-old  army  officer  met  with  a  severe  automobile 
accident  at  night,  so  that  he  had  to  be  carried  unconscious  to  a  hospital. 
There  several  insignificant  wounds  from  splinters  of  glass  and  a 
wound  on  the  forehead  were  found,  and  the  patient  gradually  recov- 
ered consciousness.  After  the  application  of  an  ase])tic  dressing  he 
was  sent  home  alone.  In  the  next  few  days  the  dressing  was  changed 
several  times  by  a  consulting  surgeon,  but  l)eyond  that  nothing  was 
done.  The  injured  man  felt  fairly  well  except  on  tlie  first  two  days, 
when  he  complained  of  a  headache  and  occasional  delirium.  The 
temperature  on  these  two  evenings  was  TOO..).  l)ut  it  tlien  fell  to 
normal.  According  to  the  report  of  tiie  house  jjjiysician,  the  pulse 
was  always  subnormal,  but  at  times  it  fell  as  low  as  52  beats  to  the 
minute. 

Eight  days  after  the  injury,  after  the  patient  had  eaten  a  consider- 
able dinner  at  three  o'clock  in  the  afternoon,  he  was  taken  with  severe 
cramps  and  convulsions,  whicli  developed  into  a  deep  coma ;  the 
cramps  lasted  at  least  five  mimites  and  the  unconsciousness  for  half 
an  hour.  Examination  at  the  beginning  of  recovery,  when  we  were 
called  in,  showed  normal  fundus  and  j)ui)illary  reactions  and  no  sen- 
sory or  motor  disturbances  anywhere  over  the  body,  but,  on  the 
other  hand,  there  was  a  severe  headache  in  the  frontal  region,  which 
lasted  until  anesthesia  was  started  at  7. -30  that  night.     The  X-ray 


82  TREATMENT  OF  WOUNDS  OF  THE  HEAD 

showed  several  depressed  splinters  in  the  middle  of  the  frontal 
bone. 

In  the  middle  of  the  forehead  there  was  found  an  oblique  fresh 
scar  4  cm.  long.  This  scar  was  excised,  whereupon  it  appeared  that 
to  the  right  side  the  periosteum  was  loosened  by  granulations,  so  that 
the  bone  was  exposed  and  the  surface  was  pallid.  After  this  obser- 
vation a  traji-door  of  skin  and  bone  with  its  base  to  the  right  was 
made.  The  two  drill  holes  were  bored  in  the  middle  line  where  the 
scar  had  been  excised.  The  lower  drill  hole  opened  into  the  frontal 
sinus,  and  after  the  anterior  bony  plate  was  penetrated  the  posterior 
plate  had  to  be  drilled.  From  the  upper  drill  hole  there  appeared  a 
turbid  seropiu'ulent  fluid  followed  by  blood.  The  bony  incision  was 
made  in  the  ordinary  manner  with  the  Dahlgren  forceps. 

Immediately  on  turning  back  the  flap  two  large  bony  splinters  and 
one  small  one  were  discovered  projecting  into  the  dura.  In  addition  a 
fissure  ran  to  the  right  for  some  distance,  and  between  the  dura  and  the 
bone  was  found  a  thick,  somewhat  decomposed  blood  clot.  About  1  cm. 
more  of  bone  had  to  be  removed  at  the  right  in  order  to  allow  the 
removal  of  the  clot.  In  the  direction  of  the  root  of  the  nose  we  found 
a  large  and  a  small  splinter  of  bone  projecting.  The  frontal  bone 
below  was  cracked  over  a  considerable  area;  a  large  splinter  of  bone, 
which  included  the  entire  glabella,  was  allowed  to  remain,  because  it 
was  attached  to  the  skin.  Above,  two  loose  flakes  of  bone  were  found 
between  the  dura  and  the  lamina  vitrea  and  removed.  No  fm-ther 
fragments  could  be  felt.  Finally  the  right  temporal  lobe  and  the  left 
in  its  median  fourth  were  exposed,  both  naturally  covered  with  dura, 
as  well  as  the  longitudinal  sinus  in  the  entire  extent  of  the  wound, 
over  5  cm. 

There  now  appeared  in  the  dura  near  the  longitudinal  sinus  a  tear 
which  had  already  superficially  adhered.  In  order  not  to  meet  the 
sinus  a  dural  flap  was  made  over  the  right  frontal  lobe,  so  that  its 
base  was  directed  toward  the  sinus,  that  is  to  say  medial.  On  opening 
this  flap  it  was  apparent  that  the  tear  of  the  dura  had  just  encountered 
a  large  arachnoidal  vein,  as  a  result  of  which  the  whole  visible  portion 
of  the  brain  was  saturated  with  blood.  The  vein  was  double  tied  and 
divided.  Careful  palpation  of  the  entire  lobe  showed  nowhere  either 
splinters  of  bone  or  other  foreign  bodies.  It  was  carried  out  by  intro- 
ducing the  index  finger  near  the  falx  cerebri,  while  the  other  index 
finger  palpated  correspojidingly  on  the  outer  side.  Finally  the  whole 
subdural  space  was  packed  with  ^•^oform  gauze,  as  the  wound,  which 


COMPOUND  FRACTURE  OF  THE  SKULL  8S 

was  eight  days  old,  did  not  seem  to  be  free  of  the  possibihty  of  infec- 
tion, and  the  skin  and  bone  flap  was  sewn  down. 

Healing  was  uninterrupted.  Tlie  temperature  just  after  the  opera- 
tion rose  to  IOL'2,  pulse  UG,  but  it  fell  that  night  to  !)8.8,  pulse  76,  and 
on  the  second  evening  it  reached  100.4,  pulse  02.  When  on  the  sixth 
day  the  drainage  was  removed  a  few  drops  of  turbid  fluid  followed. 
From  that  on  the  temperature  varied  between  07.(5  and  08.8  and  the 
pulse  between  (!(>  and  7<).  On  the  eleventli  day  the  stitclies  were  taken 
out,  the  wound  being  healed,  and  on  the  fifteenth  day  the  patient  left 
liis  bed  and  two  days  later  the  hospital.  He  is  now  completely 
well. 

According  to  our  o])inion,  the  treatment  even  of  small  external 
wounds  should  not  be  limited  to  the  ajjjjlieation  of  antiseptic  or  aseptic 
dressings,  but  the  skin  wound  should  be  enlarged,  so  that  no  pockets 
or  recesses  remain,  and  all  foreign  bodies,  such  as  hair,  sand,  etc.,  as 
well  as  clot  sliould  be  removed,  splinters  of  bone  jjulled  out  and  crushed 
portions  of  the  brain  substance  and  lacerated  tissue  trimmed  away.  In 
order  to  prevent  necrosis  of  the  bone  and  later  injury  of  the  brain, 
sharp  projecting  points  in  the  bony  edges  of  the  wound  should  be 
smoothed  off  with  rongeurs.  When  the  necessitj'-  arises,  the  wound  in 
the  dura  should  be  enlarged  in  order  that  thei-e  sliould  be  no  retention 
of  blood  or  secretion,  and  in  that  way  further  destruction  encouraged. 
When  the  bleeding  has  been  carefully  controlled,  the  entire  wound 
cavity  cleaned  by  sponging  with  sterile  gauze  and  exposed  through 
wide  retraction,  it  should  be  packed  with  sterile  iodoform  gauze  to 
the  very  bottom.  If  handled  in  this  manner,  even  very  dirty  and  com- 
plicated wounds  run  a  favorable  course.  It  is  most  advantageous  to 
employ  the  gauze  in  the  form  of  strips  or  tape,  as  it  is  more  con- 
veniently removed  through  the  wide  apertures  which  are  left  in  closing 
the  wound,  after  five  or  six  days,  or  later,  as  the  ease  may  be.  Through 
partially  sewing  up  the  skin  wound  one  lessens  the  possibility  of 
prolapse  of  the  brain,  which  occurs  more  readily  if  the  pia  is  also 
torn  over  any  considerable  extent.  To  be  sure,  one  nnist  usually, 
by  means  of  a  plastic  flap,  with  or  without  periosteum,  attempt  later 
to  create  a  covering  for  a  larj^e  hernia  of  the  brain. 

The  fin-ther  treatment  of  wounds  of  the  brain  as  a  result  of  pressure 
of  bony  splinters,  particularly  fresh  injuries  of  the  centres  which 
lie  in  the  cortex,  will  be  considered  in  the  chapter  dealing  with  this 
special  region. 


84.  TREATIMENT  OF  WOUNDS  OF  THE  HEAD 

BULLET   WOUNDS  OF   THE    SKULL 

Military  practice  has  taught  us  that  perforating  bullet  wounds  heal 
best  if  only  the  surrounding  portions  of  the  skin  are  cleaned  and  an 
aseptic  dressing  applied.  Every  attempt  to  locate  the  bullet,  and  par- 
ticularly early  probing,  should  be  rejected  entirely,  since  it  increases 
the  danger  of  infection,  which  in  the  first  place  is  slight.  The  bullets 
in  many  cases  heal  in  without  irritation,  and  may  remain  in  situ  in 
soft  parts  or  in  the  brain  itself  for  the  span  of  a  lifetime  without 
causing  symptoms. 

An  indication  for  operative  interference,  according  to  these  prin- 
ciples, appears  when  bleeding,  either  from  a  sinus  or  a  large  vein 
in  the  pia  mater,  or  from  the  middle  meningeal  artery  or  one  of  its 
branches,  or  finally  from  the  carotid  canal,  gives  rise  to  evidences  of 
brain  compression  and  focal  symptoms;  and  an  examination  of  the 
course  of  the  bullet  must  be  made,  if  the  l)ullet,  which  is  itself  ordinar- 
ily sterile,  has  presumably  carried  with  it  into  the  depths  septic  par- 
ticles, such  as  bits  of  clothing. 

Fresh  bullet  wounds  of  the  skull  only  seldom  indicate  surgical  inter- 
ference: nevertheless,  the  removal  of  a  bullet,  or  at  least  the  opening 
up  of  its  path  so  far  as  this  is  possible,  may  be  indicated  after  several 
years.  Difficulties  may  arise  referable  to  splinters  or  depressions  of 
bone,  to  the  dura,  or  to  the  site  of  the  bullet.  Also  a  number  of  late 
complications  find  their  explanation  in  the  property  of  the  bullet  to 
wander.  This  wandering  may  take  place  without  symptoms  when 
areas  of  minor  significance  or  portions  of  the  brain  already  destroyed 
by  the  bullet  are  encountered,  then  only  repeated  X-ray  examinations 
Mill  give  the  necessary  information  concerning  its  changes  in  position. 
But  it  is  possible,  and  this  is  particularly  true  in  those  with  a  neuro- 
patliic  tendency  or  when  an  inherited  taint  is  present,  for  a  general 
epilepsy  to  develop.  In  other  cases  more  or  less  severe  symptoms 
develop  from  the  wandering  of  the  bullet,  which  may  be  differentiated 
according  to  the  sections  of  the  brain  which  are  involved.  At  times 
also,  infrequently,  the  basal  nerves  of  the  brain  are  compressed,  a 
circumstance  which  is  apt  to  give  very  definite  symptoms. 

The  subject  of  the  removal  of  bullets  and  other  foreign  bodies  from 
the  ])rain  will  be  taken  up  later. 

TREATMENT   OF   INFECTED   AVOUNDS    AND   SEPTIC    PROCESSES.      INCISION 

OF  PHLEG.MON 

Infected  wounds,  abscesses  and  all  spreading  purulent  inflamma- 


INFECTED  WOUNDS  AND  SEPTIC  PROCESSES  85 

tions  on  the  head  demand  deep  incision  of  the  infiltrated  tissue,  on 
account  of  the  danger  of  extension  of  infection  into  the  cranium.  The 
incision  should  he  made  hcyond  the  boundaries  of  the  inflammatory 
infiltration  in  depth  as  well  as  in  superficial  extent,  so  that  the  tissue 
Avill  spread  open  and  the  secretions  flow  off  unhindered.  Absorption 
of  the  wound  secretions  is  promoted  by  light  packing,  drainage  and 
moist  dressings.  One  should  not  hesitate  to  open  wide  by  counter 
incisions  the  deepest  pockets  of  the  infected  wound. 

All  phlegmonous  processes,  whether  they  originate  fi-om  diseased 
teeth,  glandular  abscesses,  infected  wounds  on  tlic  face,  mouth,  or 
from  within  tiie  nose,  should  be  laid  wide  open  in  a  similar  manner. 

Although  in  the  first  place  the  incision  must  open  up  the  infiltrated 
area  to  its  entire  extent,  at  the  same  time  regard  must  be  paid  to  the 
facial  nerve,  since  the  division  of  its  branches  maj'  result  in  permanent 
paralysis.  One  may  avoid  cutting  the  facial  nerve  with  assurance  by 
kee])ing  outside  of  a  triangle,  the  apex  of  which  lies  at  a  point  where 
the  lobe  of  the  ear  meets  the  skin  of  the  cheek  and  the  base  lies  on  a 
line  between  the  outer  end  of  the  eyebrow  and  the  corner  of  tfie 
mouth.  If  an  incision  has  to  be  made  within  this  triangle,  its  direction 
should  be  in  a  line  radiating  from  the  apex.  The  supra-maxillary 
branch  for  the  lower  lip  is  not  always  easily  avoided;  as  a  rule  it  runs 
just  behind  and  parallel  to  the  margin  of  the  jaw,  but  its  position 
is  irregular.  Kven  in  deep  cellulitis  of  the  face,  developing  from 
carious  teeth  or  other  foci  which  lie  deep,  which  creeps  forward  upon 
the  masseter  and  spreads  out  under  the  strong  temporal  fascia,  the 
necessary  incision  may  be  made  so  that  no  injury  to  the  facial  nerve 
results. 

TRKATMENT    OF    ruRUNCI.ES 

The  treatment  of  furuncles  on  the  head  and  face  dej)ends  upon  their 
position,  the  condition  of  their  develoj)ment,  whether  tlu'y  are  single 
or  multiple,  and  particularly  whether  the  symptoms  are  local  or 
general. 

Oi-dinarily  the  treatment  of  ripe  furuncles  is  simj)le  and  well  under- 
stood. They  are  recognized  by  a  complete  or  nearly  comjjlete  necrosis 
of  a  hair  folHcle  and  a  softening  down  of  the  neighboiing  tissue  within 
the  limits  of  a  small  reddened  and  swollen  area.  At  the  most  a  portion 
of  the  lymph  nodes  of  the  region  may  be  indurated  and  tender.  Such 
a  furuncle  heals  as  soon  as  the  slough  and  crust  which  covers  it  have 
been  removed  by  forceps  and  the  softened  or  liquefied  tissue  has  been 


86  TREATMENT  OF  WOUNDS  OF  THE  HEAD 

allowed  exit  by  a  crucial  incision.  The  further  the  softening  has  gone, 
the  smaller  may  be  the  incision  and  as  a  result  the  less  the  scar.  Heal- 
ing follows  under  soothing  ointment  dressings  or,  if  the  skin  will 
stand  it,  a  moist  mildly  antiseptic  dressing. 

If  one  is  scrupulous  about  the  scar  which  results  from  incision  in 
inflamed  tissues,  the  removal  of  the  slough  and  the  emptying  of  the 
fluid  portions  of  the  infected  focus  may  be  undertaken  with  a  suction 
cup  after  the  method  of  Klapp.  For  a  half  hour  several  times  a  day 
it  is  api)lied  for  five  minutes  at  a  time  with  a  pause  of  three  minutes. 
The  edge  of  the  suction  cup,  as  well  as  the  vicinity  of  the  furuncle, 
must  be  well  greased.  In  this  way  the  sliding  off  of  the  glass  and 
the  injurious  pressure  of  its  edges  will  be  prevented,  and  the  sur- 
rounding tissue  be  protected  from  exposure  to  further  infection 
through  the  pus  evacuated.  The  negative  pressure  in  the  glass  should 
never  be  so  strong  as  to  cause  pain.  The  hyperemia  which  is  obtained 
by  suction  exerts  a  painless  and  healing  influence  upon  the  course 
of  inflammation. 

Unsoftened  fresh  furuncles  may  be  healed  without  pus  formation 
by  the  ajiplication  of  an  unirritating  ointment  sjiread  over  the  surface 
of  the  hyperemia  induced  by  the  suction  cup ;  or  a  moist  90  per  cent, 
alcohol  dressing  covered  with  some  impermeable  material  with  holes 
cut  in  it  exercises  a  favorable  influence.  If  under  this  treatment 
healing  does  not  result,  the  application  works  as  a  poultice,  which 
hastens  local  softening. 

One  should  discontinue  the  bloodless  treatment  as  soon  as  an  ex- 
tending thrombosis  is  apparent  in  the  neighborhood  of  a  furuncle.  If 
hard  and  sensitive  cords  may  be  felt  by  careful  palpation  of  the  skin, 
the  infected  tissues  must  be  deeply  and  widely  opened  in  order  to 
jjrevent  transportation  of  purulent  particles  into  the  circulation,  and 
a  pyemic  intoxication.  For  the  same  reason  squeezing  and  pressure 
u])on  the  infiltration  region  about  the  furuncle  should  be  guarded 
against. 

The  ordinarily  harmless  but  protracted  multiple  furunculosis 
should  also  be  treated  after  the  foregoing  principles.  They  extend 
their  chronic  com-se  over  the  limbs,  over  the  hair  line  on  the  neck  and 
over  the  entire  body.  In  conjunction  we  have  the  formation  of  all 
manner  of  furunculous  nodes,  which  vary  in  size,  painfulness  and  in 
the  stage  of  inflammation.  The  funmcidosis  of  nurslings,  which 
spreads  all  over  the  body,  is  particularly  prone  to  abscess  formation. 
It  heals  up  most  rapidly  when  each  single  abscess  is  opened  by  incision 


TREATMENT  OF  FURUNCLES  87 

under  proper  precautions.  In  this  way  sometimes  we  have  to  make 
150  to  200  incisions  in  the  course  of  several  weeks  in  infants  before 
it  is  finally  overcome.  We  have  never  seen  the  slightest  result  either 
therapeutically  or  prophylactically  from  the  use  of  yeast.  Vaccine 
thera2)y  sometimes  acts  well  in  chronic  cases. 

Furuncles  of  the  upper  lip  and  cheek  follow  in  the  majority  of 
cases  the  same  clinical  course  as  isolated  furuncles  in  other  portions 
of  tile  body.  They  may,  however,  be  very  virulent,  and  they  are 
particularly  disposed  to  indvice  pyemia  and  purulent  meningitis.  For 
that  reason  they  should  always  be  considered  and  treated  as  a  danger- 
ous affection.  The  severity  of  the  symptoms  does  not  give  indication 
of  their  possibilities.  The  ordinary  malaise,  fever  and  local  changes 
are  exhibited  to  a  greater  extent  in  the  face  than  in  other  locations. 
The  inflammatory  edema  usually  extends  to  the  up^jer  portion  of  the 
face,  so  that  one  or  both  eyes  may  be  closed  by  swelling  of  the  lid. 
In  fiu'uncle  of  the  lip  the  entire  lip  may  project  like  a  proboscis,  and 
on  the  nose  the  soft  parts  may  exhibit  so  great  a  swelling  that  the 
nasal  passages  are  closed. 

The  particular  danger  in  lip  and  cheek  furuncles  consists  in  the 
tendency  for  the  infection  to  extend  to  the  facial  vein  and  its  branches. 
By  this  means  masses  may  be  carried  off  to  the  most  remote  places. 
In  j)yemia  after  funmcles  of  the  face,  the  joints  of  the  lower  extrem- 
ities and  the  pararenal  tissue  are  particularly  involved.  I^ess  favor- 
able even  than  pyemia  is  the  course  of  an  extensive  putrid  thrombosis 
of  the  face.  This  may  involve  the  sinus  cavernosus  and  other  vessels 
of  the  base  of  the  skull.  It  may  include  the  veins  of  the  eye  or  may 
even  induce  a  purulent  meningitis. 

Since  the  course  of  a  lip  or  cheek  furuncle  cannot  be  foreseen  and 
since  it  may  lead  to  a  fatal  termination,  one  is  justified  in  making 
early  and  extensive  incisions  in  order  to  open  up  the  infiltrated  tissue. 
Such  a  radical  procedure  is  particularly  indicated  if  the  development 
of  the  inflammatory  changes  does  not  remain  limited  to  the  neighbor- 
hood of  the  furuncle,  but  if  in  the  course  of  the  disease  a  hard  cord 
painful  to  pressure  appears  at  the  site  of  the  facial  vein. 

^^'hile  early  incision  of  the  furuncle  has  been  demanded  in  every 
case  by  the  majority  of  surgeons,  recently  efforts  have  been  made 
along  the  line  of  conservative  and  bloodless  treatment.  This  point 
of  view  has  its  justification  in  the  fact  that  uncomplicated  lip  and 
cheek  furuncles  run  a  benign  course  in  the  majority  of  cases  if  they 
are  protected  from  all  mechanical  insult.     Particularly  all  palpation 


88  TREATMENT  OF  WOUNDS  OF  THE  HEAD 

and  squeezing  of  the  affected  area  must  be  avoided  in  order  not  to 
force  bits  of  necrosed  tissue  or  bacteria  tliemselves  into  the  rich 
lymphatic  and  blood  circulation.  Chewing  and  talking  should  be  lim- 
ited as  far  as  possible  for  the  same  reason.  The  patient  should  be 
kept  in  bed  and  treatment  should  otherwise  be  limited  to  covering 
the  furuncle  Avith  a  piece  of  compress  thickly  smeared  with  ointment, 
to  protect  it  and  to  overcome  the  feeling  of  tension.  In  the  clinic  of 
Bier  a  light  hyperemia  M'ith  the  rubber  bandage  about  the  neck  for 
twenty  to  twenty-two  hours  is  employed.  We  can  obtain  a  definite 
result  with  the  suction  cup,  as  in  other  furuncles,  only  when  a  necrotic 
slough  has  been  already  formed  in  the  centre. 

TREATMENT    OF    CARBUNCLE 

The  same  principles  are  employed  in  the  treatment  of  carbuncle 
as  for  furuncle  of  the  face.  Since  the  purident  infiltration  includes 
several  hair  follicles,  it  is  clear  that  the  danger  increases  with  the 
circumference  of  the  focus. 

Carbuncles,  like  furuncles,  are  particularly  malignant  on  the  lip. 
They  demand,  on  account  of  the  danger  of  metastasis,  an  early  and 
broad  incision  along  the  border  of  the  mucous  membrane  of  the  upper 
lip.  This  incision  divides  the  mass  in  a  line  which  will  give  a  scar 
of  passable  cosmetic  appearance.  If  such  a  splitting  of  the  infiltrated 
area  does  not  sufl^ce,  another  incision  is  made  at  right  angles  to  it 
directly  across  the  infiltrated  tissue.  This  sometimes  exposes  the 
facial  vein,  which  must  be  tied  off.  In  contrast  to  this  radical  pro- 
cedure. Bier  recommends  treatment  with  passive  hyperemia  just  as 
for  furuncles. 

The  danger  of  metastasis  of  jiurulent  material  to  the  other  parts 
of  the  body  is  more  safely  avoided  by  excision  of  the  carbuncle.  This 
radical  procedure  is  to  be  considered  on  the  face  only  in  severe  cases. 
But  according  to  Riedel,  all  neck  and  back  carbuncles,  without  regard 
to  their  circumference,  should  be  extirjjated  just  as  a  malignant 
growth,  a  procedure  which  we  have  followed  as  a  rule,  and  which  may 
be  typified  by  the  following  observation: 

A  thii'ty-year-old  man  had  a  carbuncle  the  size  of  a  baby's  fist 
on  the  right  side  of  the  neck.  In  order  to  excise  it  entirely,  the  skin 
was  divided  at  a  distance  of  several  mm.  from  the  border  of  the 
infiltrated  zone.  An  elliptical  incision  being  made  on  each  side,  so 
that  the  ends  met  above  and  below  (Fig.  2,  Plate  1),  the  carbuncle 
was  seized  by  double  hooks  and  was  extirpated  by  incision  through 


Krause-Heymann-Ehrenfried. 


Tab.  1. 


Excision   of  a   Carbuncle. 


Carbttn<le 

Fife.  2.  Elliptit'orm  incision  of  tiie  skin. 


Ed^e  of  Doiihle  /looks 

norma/  exerting  Irarlion 

lissiie  on  cai/inndc 

Fig.  3.  Deep  dissection. 


Musc/e, 

freed 

from  fnscia 


I'ii;.  4.  Wound  after  extirpation. 


Rebmaii  Company,  New  York. 


TREATMENT  OF  CARBUNCLE  89 

normal  tissue  just  like  a  tumor.  To  be  sure  that  it  was  entirely  re- 
moved, the  wound  edges  were  held  apart  with  retractors  under  con- 
siderable tension  (Fig.  3,  Plate  1 ) .  It  became  necessary  to  remove  at 
the  same  time  the  infiltrated  fascia  of  the  neck,  as  well  as  tlie  super- 
ficial layer  of  muscle,  so  that  after  the  complete  extirpation  a  clean 
wound  remained  (Fig.  4,  Plate  1).  The  entire  wound  cavity  was 
packed  with  iodoform  gauze  and  a  moist  dressing  applied. 

Two  days  later  the  dressing  was  removed,  the  wound  appeared 
clean  and  showed  only  a  few  purulent  points.  Fight  days  after  the 
extirpation  it  was  covered  by  fresh  granulations,  after  which  the  light 
antiseptic  dressing  was  changed  every  day.  On  the  same  day  the 
entire  defect,  after  undermining  the  skin  edges,  was  closed  by  sec- 
ondary suture,  and  the  patient  was  discharged  a  week  later. 

Small  carbimcles,  if  the  infiltration  does  not  go  very  deep,  or  the 
discoloration  of  the  skin  does  not  extend  far  beyond  the  purulent 
points  on  the  surface,  may  be  split  open  by  crucial  incisions.  As 
soon  as  all  slough  has  come  away  and  the  inflammation  has  disap- 
peared, the  foiH'  corners  of  skin  formed  by  the  incision  come  together 
over  the  granulations.  To  avoid  a  disfiguring  scar,  secondary  suture 
may  be  employed  in  this  case  also.  But  if,  as  occurs  in  diabetes,  a 
deep,  woody  infiltration  is  present  over  the  entire  neck  from  one  ear 
to  the  other,  and  the  skin  on  the  elevated  portions  shows  a  gray-red 
to  whitish  color  and  a  disposition  to  necrosis,  the  crucial  incision  is 
useless  and  extirpation  alone  can  put  an  end  to  extension  and  the 
dangerous  possibilities  of  general  infection.  In  diabetics  tlie  larger 
portion  of  the  discolored  skin  in  carbuncle  of  the  neck  becomes 
necrotic;  since  the  crucial  incision  cannot  open  uj)  all  the  infiltrated 
region  under  the  flaps,  radical  removal  of  the  infected  tissue 
stands,  as  a  matter  of  course,  as  the  most  suitable  metliod  of  treat- 
ment. 

In  extensive  carbuncle  of  the  neck,  excised  with  a  knife  in  a  fashion 
similar  to  that  shown  in  Plate  1,  it  is  advisable  to  begin  the  incision 
at  the  lower  edge  of  the  carbuncle,  so  that  the  blood  flowing  down 
from  above  does  not  interfere  witli  the  field.  The  wound  edges  are 
held  apart  inider  considerable  tension  in  order  to  see  how  far  the 
purulent  softening  extends  into  the  depths.  The  strongest  venous 
or  arterial  bleeding  may  be  controlled  by  pressure  of  gauze  sponges 
on  the  wound  surface  during  the  few  seconds  which  are  needed  from 
the  beginning  of  the  upjier  incision  until  its  removal.    As  a  ruk\  it  is 


90        TREATMENT  OF  WOUNDS  OF  THE  HEAD 

not  necessary  to  seize  the  vessels,  which  at  the  beginning  bleed  rather 
severely. 

After  the  extirpation  of  a  carbuncle,  the  edges  of  the  open  wound 
are  apt  to  fall  together  rapidly,  and  after  a  week  all  the  necrosed 
material  has  separated  and  the  inflammatory  edema  has  so  far  dis- 
appeared that  a  practically  flat  surface  remains.  Sometimes,  to  be 
sure,  this  pi'ocess  lasts  longer.  During  this  stage  nothing  does  better 
than  a  salt  and  citrate  dressing.  As  soon  as  the  wound  has  become 
clean  the  defect  may  be  closed  by  mobilization  of  the  skin  edges  and 
secondary  suture,  or  less  advantageously  by  means  of  Reverdin  or 
Thiersch  skin  grafts.  If  such  a  secondary  operation  is  deemed  inad- 
visable for  any  reason,  excellent  results  may  be  obtained  by  the  use  of 
scarlet  red  or  fuchsin  ointments. 


Krause-He>  mann-Ehrenfried. 


Tab.  2. 


Excision    of  a   cystic   Endothelioma. 


Incision 

\         Portion  of  tumor  at/herent  to  skin 


Fig.  5.  Elliptiform  incision  tlirongh  skin. 


Retracted  lower  edge 


Fig.  6.  Dissection  of  fat  of  cheek. 


Forceps  exerting  traction  on  tnnior 

Fig.  7.  Completion  of  the  extirpation. 


Rebman  Company,  New  York. 


Cut  Surface 


Subcutaneous  fat 

Fig.  8.  Tumor,  split  after  removal. 


CHAPTER  6— EXTIRPATION  OF  TUMORS  IN  THE 
TISSUES  OF  THE  FACE 

SM^iLL    AND    BENIGN    GROWTHS:    LIPOMA,    FIBUOMA,    SEBACEOUS    CYSTS, 

FIBRO-EPITHELIAL   TUMORS 

The  removal  of  small  benign  tumors  or  tumor-like  formations  on 
the  soft  parts  of  the  face  can,  as  long  as  the  skin  is  not  adherent  to 
them,  be  carried  out  subcutaneously  through  a  linear  incision.  If  the 
skin  has  become  adherent  to  the  tumor  or  has  been  partly  destroyed, 
the  t>imor  must  l)e  shelled  out  after  an  oval  incision. 

Injuries  of  the  branches  of  the  facial  nerve  may  be  avoided  in  most 
cases  in  the  manner  described  vmder  purulent  infiltrations.  The 
incisions  should  run  in  radiating  fashion  forward  from  the  root  of 
the  lobe  of  the  ear,  and  so  long  as  one  continues  parallel  to  the  line 
of  incision  and  divides  the  deep  layers  carefully,  danger  of  cutting 
across  the  nerve  is  not  great.  This  is  diminished  if  the  tumor  in 
growing  to  the  surface  has  pushed  the  nerve  fibres  to  one  side. 

As  an  example  of  the  removal  of  a  tumor  from  a  cheek  the  follow- 
ing observation  may  serve:  A  tumor  the  size  of  a  cherry  was  apparent 
upon  the  left  cheek  of  a  young  woman  just  in  front  of  the  edge  of 
the  parotid  and  on  the  level  of  the  lower  teeth.  It  was  very  slightly 
movable  upon  the  deep  tissues;  the  skin  had  become  adherent  to  it. 
Since  it  was  probably  a  case  of  cystic  adenoma,  the  extirpation  was 
carried  out  in  a  short  ether  "rausch." 

The  skin,  which  had  grown  to  the  tumor,  had  to  be  incised  in  tlie 
form  of  an  oval  (Fig.  5,  Plate  2)  until  the  wound  edges  above  and 
below  could  be  retracted  with  sharp  hooks  (Fig.  6,  Plate  2)  and  the 
whole  tumor  could  be  cut  out  with  a  wide  margin  of  normal  tissue 
(Fig.  7,  Plate  2).  Since  all  the  incisions  were  made  in  the  direction 
of  the  branches  of  the  facial  nerve  and  the  separation  of  the  subcu- 
taneous tissue  was  carried  out  carefully,  injury  to  the  nerves  was 
avoided.  After  ligation  of  the  spurting  vessels,  the  oval  incision  \vas 
sewed  up  in  a  straight  line. 

Out  of  the  removed  tumor  (Fig.  8,  Plate  2)  there  poured  a  thin, 
seromucous  content.  The  inner  wall  of  the  cyst  was  thin,  smooth, 
white  and  shiny.  It  lay  everywhere  embedded  in  fat  except  on  the 
outside,  wluic  it  had  grown  to  the  epidermis.  No  connection  with  the 
j)arotid  could  be  made  out. 

91 


92  TUMORS  OF  THE  FACE 

HEMANGIOMA   OF  THE   FACE:    HEMANGIOMA   SIMPLEX 

In  the  new-born  or  in  children  in  the  first  months  of  hfe,  on  the  skin 
of  the  face  more  frequently  than  in  other  parts  of  the  body,  a  tiny, 
level,  fiery  red  birth  mark  may  appear.  On  close  examination  one 
can  recognize  at  the  edge  of  the  affected  area  individual  ectactic  blood 
vessels,  of  which  the  entire  mass  of  the  formation  is  composed.  Such 
hemangioma  may  grow  rapidly  and  in  the  course  of  months  and  years 
spread  to  include  the  lips,  nose,  lids  and  ears.  On  account  of  this  it 
is  advisable  to  remove  small  red  birth  marks  which  lie  near  the  orifices 
of  the  face  as  soon  as  they  show  a  disposition  to  extend.  This  is  best 
carried  out  in  the  first  weeks  of  life  with  a  Paquelin  cautery,  carbon 
dioxide  snow,  or  liquid  air.  Larger  hemangioma  must  be  excised  and 
the  skin  defect  closed  by  suture  or,  if  necessary,  covered  by  epidermal 
transplantation. 

ANGIOMA  CAVEKNOSUM 

Cavernous  angioma,  just  as  the  simple  isolated  angioma,  is  usually 
congenital  or  arises  in  the  first  few  years  of  life.  It  is  composed  of 
a  crowded  throng  of  blood  sinuses,  which  contain  venous  blood.  If 
these,  in  their  growth,  press  through  to  the  surface  of  the  skin,  they 
appear  as  blue  knots  or  varicosities  through  the  skin  of  the  cheek  and 
the  margin  of  the  lip.  On  the  other  hand,  they  may  grow  deep  into 
the  fatty  pad  of  the  cheek,  so  that,  after  Virchow,  they  have  been  also 
named  lipogenous  angioma.  As  an  example  of  the  appearance  and 
treatment  of  these  timiors,  the  following  observation  may  serve: 

A  nine-months-old  child  Avas  born  with  an  angioma  on  the  scalp 
the  size  of  the  head  of  a  pin  and  a  varix  on  the  cheek  the  size  of  a 
grape  seed.  Gradually  the  tumor  of  the  cheek  grew,  and  while  it 
was  still  about  the  size  of  a  quarter  an  attempt  had  been  made  to 
destroy  it  with  alcohol  injections.  As  a  result  the  tumor  and  the 
skin  which  covered  it  became  gangrenous.  In  a  short  time  erysipelas 
set  in,  starting  from  the  wound  of  the  cheek  and  spreading  over  the 
entire  body  of  the  child,  which  put  an  end  to  further  treatment.  After 
the  erysipelas  and  a  series  of  posterysipelatous  abscesses  in  various 
portions  of  the  body  were  healed,  the  tumor,  which  had  been  destroyed 
in  its  centre,  had  attained  the  size  of  a  small  apple  (Fig.  9,  Plate  3) . 

For  the  extirpation  of  the  scars  and  the  skin  of  the  cheek,  which 
had  become  adherent  to  the  tumor,  an  oblique  oval  incision  was  made 
(Fig.  10,  Plate  4),  directed  downwards  and  inwards,  because  it  was 
apparent  that  in  this  way  distortion  of  the  ej'elids  and  of  the  corner 


Krause-Heyinann-Ehrenfried. 


Tab.    3. 


An^ioni.-i   cax'crnosuni    of  the    check.   I. 


Scarred  portion  of  the  tumor 


^ 


..^ 


w\ 


Fig.  *i.   Tiie  skin  has  been  destroyed  as  a  result  of  alcohol  injections. 


;ebni;in  Company,  Ne*  York. 


Krause-Hevniann-Ehrenfried. 


Tab.  4. 


Tumor 


Extirpation   of  an   Angioma  of  the  cheek.   11. 

Zygoma 


Muscles  of 

the  corner  of 

the  mouth 


I  he  finger  within  the  mouth  pushes 
out  the  mucous  membrane 


Fat  of  cheek 

Fig.  10.  The  tumor  which  has  been  dissected  remains 
attached  only  by  a  strip  of  connective  tissue 


Fig.  11.  Completion  of  the  Extirpation. 


Scar 


Redundant  fold  of  skin 

Fig.  12.  The  face  healed  without  distortion  of  the  features. 


Rebnian  Company,  New  York. 


.\NGIOMA  98 

of  the  mouth  would  be  kept  at  a  niininiuni.  The  incision  first  sep- 
arated only  the  skin  about  the  tumor.  At  the  forward  ed^e  the  dis- 
section was  carried  on  until  the  base  of  the  tumor  was  perfectlj'  free; 
every  spurting  vessel  was  seized  and  tied  off.  The  same  was  done  in 
the  lower  border  and  in  the  neighborhood  of  the  corner  of  the  mouth. 
The  tumor  here  went  into  the  depths  as  far  as  the  mucous  membrane 
of  the  mouth,  but  it  was  not  adherent  to  this.  In  order  not  to  destroy 
this  and  in  that  wav  favor  infection  of  the  wound,  the  little  finger  of 
the  right  hand  was  placed  in  the  mouth  and  with  this  the  mucous 
membrane  was  pressed  forward  so  that  the  tumor  might  be  separated 
from  the  submucosa  piecemeal  with  scissors  (Fig.  11,  Plate  4) .  Here 
likewise  all  spurting  vessels  were  immediately  seized  and  tied. 

After  freeing  the  skin  of  the  cheek  behind,  the  tumor  could  be 
exposed  down  to  the  fat  pad  of  the  cheek  and  the  zygoma.  Out  of 
regard  for  the  later  cosmetic  effect  the  fat  of  the  cheek  was  preserved 
so  far  as  possible. 

When  the  tumor  was  freed  from  its  bed  and  removed,  the  muscles 
which  run  to  the  corner  of  the  mouth  were  exposed  as  well  as  the 
zygoma  and  the  fat  pad  of  the  cheek.  P^inally  the  skin  was  sewn 
up  with  interrupted  sutures  without  causing  any  deformity  or  displace- 
ment of  the  lid  or  corner  of  the  mouth. 

After  completion  of  the  suture  the  small  angioma  on  the  scalp  was 
excised  by  an  oval  incision.  In  such  an  excision  all  bleeding  may  be 
prevented  if  an  assistant  presses  upon  the  bony  substructure  with  the 
fingers  on  either  side  of  the  designed  incision  and  a  continuous  button- 
hole stitch  is  placed  while  the  compression  is  continued. 

At  first  the  right  corner  of  the  mouth  was  paralyzed  so  that  in 
crying  and  laughing  the  mouth  was  di-awn  strongly  to  the  left,  but 
this  impi-oved  within  the  next  ten  days  and  upon  discharge,  fourteen 
days  after  the  operation,  only  a  very  slight  paresis  persisted. 

The  wound  healed  smoothly,  so  that  on  the  seventh  day  the  stitches 
could  be  removed.  At  the  lower  corner  of  the  mouth  a  little  fold  of 
skin  had  resulted  from  the  suture,  which  at  first  projected  consider- 
ably, but  by  the  day  of  discharge  it  had  fiattened  out  to  a  small  ele- 
vation. The  linear  wound  of  the  cheek  was  only  noticeable  on  account 
of  its  redness  (Fig.  12,  Plate  4).  The  scar  on  the  head  was  hardly 
visible. 

RACEMOSE  ARTEKIAI,  HEMANGIOMA 

Much  less  frequent  than  simple  and  cavernous  tumors  on  the  face 
and  the  head  is  the  arterial  angioma.    It  is  apt  to  develop  as  a  "creep- 


94  TUMORS  OF  THE  FACE 

ing"  angioma  in  the  neighborhood  of  the  ear,  and  it  then  stands  in 
relation  to  the  superficial  arteries.  Its  recognition  depends  upon 
palpation  and  upon  pulsation.  Avhich  is  usually  visible.  Although  the 
skin  lies  over  it  only  in  a  thin  bluish  layer,  the  single  Acssels  as  a  rule 
are  not  visible.  The  following  case  cited  by  H.  Berger*  is  repre- 
sentative : 

A  nine-year-old  boy  had  since  birth,  according  to  his  father,  a  tumor 
on  the  right  side  of  the  head,  which  at  times  showed  an  increase  in 
size  and  at  other  times  was  stationary.  Several  weeks  before  his 
admittance  to  the  hospital  the  tumor  had  begun  to  grow  rapidly,  and 
the  right  eye,  which  had  previously  not  been  involved,  had  begun  to 
swell.  There  was  no  pain.  According  to  the  parents,  he  at  times 
complained  of  headache  but  not  of  roaring,  buzzing  or  similar  mani- 
festations. 

On  the  right  side  of  the  head  was  a  broad  tumor  for  the  most  part 
movable  imder  and  with  the  skin  over  the  bone,  made  up  of  numerous 
coils  of  vessels,  which  jjulsated  synclironously  with  the  heartbeat. 
With  the  pulsation  one  could  feel  and  hear  in  the  tumor  a  definite 
thrill.  The  temporal  artery,  which  was  the  size  of  a  lead  pencil, 
showed  marked  pulsation,  and  unusual  pulsation  was  also  to  be  seen 
in  the  neighborhood  of  the  tumor  and  even  in  the  neck  and  clavicular 
fossa.  The  extent  of  the  tumor  Avas  as  follows:  The  lower  border, 
beginning  at  the  right  tragus,  ran  obliquelj'  upwards  to  the  outer 
corner  of  the  eye  and  through  the  upper  lid  as  far  as  the  glabella. 
From  here  it  went,  following  the  sagittal  sutin-e,  upwards  to  the  middle 
of  the  frontal  bone.  Only  in  the  region  of  the  anterior  edge  of  the 
scalp  did  it  pass  beyond  the  middle  line.  From  the  middle  of  the 
temijoral  bone,  the  posterior  border  of  the  tumor  returned  to  the  right 
ear  and  from  the  concha  of  the  ear  back  to  the  tragus.  The  pulsation 
in  the  tumor  could  not  be  decreased  either  by  compression  of  the 
common  carotid  artery  or  at  any  point  between  that  and  the  tumor. 
The  right  upper  lid  was  a  dark  bluish  red  and  swollen,  but  the  lobe 
was  not  pushed  forward  and  the  fundus  as  well  as  the  vision  was 
normal. 

At  the  operation,  through  a  skin  incision  which  ran  obliquely  from 
the  outer  corner  of  the  eye  downward,  in  the  direction  of  the  facial 
branches,  to  the  tragus,  the  temporal  artery  and  numerous  other 
arteries  the  size  of  a  lead  pencil,  which  were  exposed,  were  double  tied 
and  divided.    This  tying  off  affected  only  that  part  of  the  tumor  which 

•Bruns  Beitrage  z.  klin.  Chir.  XXII. 


iie:\iant,T()ma  95 

lay  just  in  front  of  the  ear,  otherwise  the  pulsation  continued.  From 
a  second  skin  incision  above  the  glabella  the  hcniorrhatife  was  just  as 
stron<>'  as  in  the  first.  Here  the  skin  vessels  were  compressed  between 
two  fingers  and  the  incision  carried  down  to  the  periosteum.  The 
supra-orbital  artery  was  exposed  as  a  thick  cord  and  between  double 
ligatures  it  was  divided.  The  second  incision  was  then  carried  obliquely 
through  the  upjjcr  lid  until  it  met  the  first,  and  down  througli  the 
entire  tumor  mass,  so  that  the  cut  vessels  could  easily  be  seized  and 
tied.  Only  a  lew  of  the  larger  and  more  easily  exposed  vessels  were 
tied  before  cutting. 

After  completion  of  the  skin  incision  and  most  of  the  ties,  the  entire 
tumor  along  tlie  lower  oblique  incision  from  the  upper  lid  down, 
together  with  skin,  muscle  and  fascia,  was  freed  from  the  healthy  under 
layer  with  the  help  of  raspatory,  which  made  more  tying  off  necessary. 
In  se\eral  places  the  periosteum  had  to  be  taken  away  because  in  and 
and  under  it  further  arteries  were  present.  Repeatedly  vessels  spurted 
directly  out  of  bone  and  could  onlj'  be  stoj^ped  by  boring  in  with  a 
pointed  clamp.  The  bone  itself  was  everywhere  intact.  After  about  one- 
half  of  the  tumor  was  freed  from  its  base  in  this  manner,  the  operation 
had  to  be  intcrru])ted  on  account  of  the  condition  of  the  patient.  The 
wound  was  packed  with  .)  per  cent,  iodoform  gauze  and  a  light  pressure 
dressing  applied.  ^Ml  told  up  to  this  time  113  ties  had  been  necessary. 
For  this  reason  the  loss  of  blood  had  been  small ;  for  either  the  vessels 
were  exposed  by  the  incision  and  tied  or  the  separation  of  the  skin 
and  tumor  mass  was  accomplislied  between  the  compressing  fingers 
of  the  assistant  and  the  cut  lumina  seized  before  a  drop  of  blood 
was  lost. 

After  three  days,  during  which  no  distm-bing  symptoms  such  as 
hemorrhage  or  fever  app.'ared,  the  patient  being  in  good  condition,  the 
extirpation  of  tlie  tumor  was  completed.  It  appeared,  wliere  the  skin 
had  not  been  severed,  generally  edematous.  It  was  possible  to  free 
the  tumor  after  extending  the  skin  incision  upward  from  the  glabella 
along  the  sagittal  line  close  to  the  pericranium,  partly  by  blunt  dis- 
section and  partly  witli  tlie  scissors.  All  of  the  numerous  vessels  were 
seized,  in  the  ])eriosteum  as  well  as  the  vessels  of  the  tumor  itself, 
whicli  contimied  to  bleed  copiously.  The  bone  was  not  in  the  least 
eroded.  After  the  entire  tumor  together  with  the  skin  for  a  finger's 
breadth  around  its  border  had  l)een  turned  up,  he  created  a  flap  of 
skin  tlie  j)e(iicle  of  wliich  lay  between  the  tragus  and  the  frontal 
protuberance.     In  order  to  remove  the  tumor  from  the  skin  and  in 


96  TUMORS  OF  THE  FACE 

this  manner  to  extirpate  it,  all  the  vessels  supplying  the  tumor  through 
the  pedicle  of  the  flap  were  divided  and  the  tumor  mass  removed  from 
the  inner  surface  of  the  skin.  Even  in  this  manoeuvre  several  good- 
sized  vessels  spurted  and  had  to  be  tied.  In  some  places  the  mass 
was  so  closely  attached  to  the  skin  that  the  skin  was  buttonholed. 
After  all  traces  of  the  tumor  substance  had  been  removed,  the  skin 
flap  was  laid  back  over  the  wound  surface  and  sewed  loosely  around 
the  periphery.  In  three  places  small  fine  drains  held  the  line  open 
to  avoid  possibilities  of  danger.  In  the  second  oijeration,  which  com- 
pleted the  extirpation,  76  ties  were  necessary,  so  that  the  total  nmnber 
of  ties  was  189. 

The  operation  was  again  over  without  any  pronounced  loss  of  blood. 
A  slight  tendency  to  fever,  caused  by  partial  necrosis  of  the  flap,  dis- 
appeared within  a  few  days.  After  a  week,  the  portion  of  the  flap 
which  survived  had  healed  in  place.  The  necrosis  involved  an  area 
the  size  of  a  nickel  upon  the  right  forehead,  as  well  as  the  entire  eye- 
brow and  the  loosened  portion  of  the  right  upper  lid.  After  two  weeks 
the  patient  was  out  of  bed.  With  the  further  advance  of  the  scar  for- 
mation on  the  regions  not  covered  with  skin,  distortion  soon  became 
apparent.  The  upper  eyelid  was  pulled  up  so  far  above  the  super- 
ciliary ridge — about  one  inch — that  he  could  close  the  eye  only  by 
pulling  the  lower  lid  up  to  meet  it.  This  defect  was  covered  in  by  a 
plastic  operation  and  skin  transplantation  after  the  method  of  Krause, 
and  the  eyebrow  was  replaced  by  skin  from  the  scalp  (see  p.  152). 
After  this,  complete  recovery  occin'red.  Abnormal  pulsation  could 
not  be  made  out  either  in  the  former  tumor  region,  in  the  immediate 
neighborhood  or  at  some  distance.  The  entire  treatment  took  three 
months. 

EXTIRPATION  OF  LAKGE  OR  MALIGNANT  TUMORS  ON  THE  FACE 

The  wounds  which  result  from  the  removal  of  benign  tumors  usually 
allow  of  easy  closure  by  drawing  the  edges  together  by  direct  suture. 
This  is  the  most  successful,  in  so  far  as  one  is  as  sparing  as  possible  of 
the  normal  tissue,  because  the  skin  defects  whicli  result  are  usually 
smaller  than  the  subcutaneous  pocket  from  which  the  tumor  is  re- 
moved. 

Since  malignant  tumors  possess  the  property  of  growing  through 
the  infiltrated  tissue,  in  every  case  a  portion  of  the  neighboring  tissue 
which  does  not  appear  involved  must  be  also  removed;  for  the  borders 
of  the  tumor  and  their  transition  into  normal  tissue  are  not  recogniz- 


MALIGNANT  TUMORS  97 

able  by  the  naked  eye.  In  order  not  to  leave  behind  any  suspicious 
tissue,  the  extirpation  of  the  tumor  must  always  include  the  tissues  a 
half  inch  or  so  beyond  its  apparent  boundary.  ^Moreover,  the  zone  of 
inflammatory  infiltration,  for  instance,  whicli  surrounds  practically  all 
carcinomata,  particularly  those  of  the  skin,  should  never  extend  be- 
yond the  line  of  incision.  No  regard  should  be  paid  for  the  preserva- 
tion of  neigliboring  oryans,  nerves  and  vessels,  particularly  if  doubt 
exists  as  to  Iiow  far  the  tumor  has  proceeded. 

Naturally  with  every  radical  removal  of  a  malignant  tumor  there 
results  a  tissue  defect  of  considerable  size.  Since  the  tumor  may 
destroy  portions  of  the  face  over  a  considerable  extent,  so  the  defect 
after  extirjjation  may  extend  considerably.  Sucli  wounds  cannot  be 
closed  by  suture  alone  without  serious  mutilation,  as  after  the  removal 
of  most  benign  tumors  which  can  be  shelled  out,  but  the  loss  must 
so  far  as  possible  be  replaced  by  the  aid  of  plastic  methods.  The  worst 
cosmetic  effect  and  the  most  severe  functional  difficulties  are  suffered 
after  the  destruction  of  the  bony  framework  of  the  face  and  the  skin 
which  covers  it.  In  the  replacing  of  both  these  structures  lies  the  chief 
indication  for  plastic  operations  on  the  face. 


CHAPTER  7— PLASTIC  OPERATIONS  ON  THE  FACE 


SIMPLE   METHODS-  OF   DERMOPLASTY 

The  simplest  method  foi'  covering  surface  defects  on  the  face  is 
by  undermining  the  skin  edges  and  sewing  them  together  in  a  straight 
line.  This  method  is  adapted  only  for  small  defects.  In  larger  wound 
surfaces  one  must  make  tension  incisions  at  either  side  and  mobilize 
the  wound  edges.  Various  methods  for  doing  this  are  shown  in  the 
following  sketches,  which  are  taken  from  Hochenegg's  "Lehrbuch  der 
speziellen  Chirurgie." 


Fig.    13 


Fig.    14 


A  wound  with  irregular  edges  is  transformed  into  an  oval  \vound 
by  trimming  the  edges,  and  two  parallel  tension  incisions  are  made 
(Fig.  13)  ;  after  mobilization  of  the  flaps  the  wound  edges  are  sewed 
together  (Fig.  14). 


Fig.  15 


Fig.  10 


A  small  rectangular  surface  (Fig.  15)  is  covered  by  a  mobilized 
flap  (Fig.  16),  which  has  been  formed  between  incisions  continuing 
two  parallel  edges  of  the  wound.     (Celsus.) 


Fig.  17 


Fig.  18 


98 


Sl.Ml'LK   .MHTIIODS  OF   DKRMOPLASTY 


99 


Larjife  rectaiiuiilar  defects  (Fig.  17)  may  l)e  covered  by  several  flaps 
taken  similarly  from  two  or  more  sides  (Fig.  18). 

'riiree-coriiered  defects  (Fig.  19)  are  covered  by  a  flap  whicli  is 
foiiind  l)y  a  cirNceiilic  incision  in  a  line  continuing  the  base  of  the 
triangle   (Fig.  20). 


■'^]^.4'!! 


Fig.  10 


Fig.  20 


Large  triangular  defects  (Fig.  21)  may  be  covered  by  a  mobiliza- 
tion of  the  wound  edges  upon  both  sides  (Fig.  22). 


Fig.  22 


Burow's  modification  (Fig.  23)  of  this  procedure  is  as  follows:  One 
edge  ( A  B )  of  the  isosceles  triangular  sm-face  is  lengthened  (ABBA). 
The  proximal  edge  (B  C)  is  mobilized  to  a  considerable  distance  and 


c 

A 


Fig.  2.3 


Fig.  24 


the  skin  is  drawn  in  the  dii-ection  of  the  arrow.  In  order  to  allow  the 
skin  to  slide  over,  a  new  triangle  (ABC)  is  excised  analogous  to  the 
first,  but  reversed,  and  the  suture  is  completed  (Fig.  24). 

Burow's  modification  for  covering  rectangular  defects  consists  in 
the  mobilization  of  the  flaj)  and  skin  sliding  after  the  excision  of  two 
tiiangles  (Fig.  2.5  and  Fig.  2(»). 


100  PLASTIC  OPERATIONS  ON  THE  FACE 

After  these  methods  all  sorts  of  superficial  woiinds  may  be  covered 
with  skin.  Numerous  opportunities  not  limited  to  the  face  will  pre- 
sent themselves,  in  which  these  simplest  of  all  plastic  methods  may  be 
used  to  practical  purpose.  Their  unlimited  employment  in  the  face 
is  not  permissible;  for  instance,  the  angles  of  the  eyes  and  mouth 
should  never  be  dragged  or  displaced,  as  tension  may  result  in  func- 
tional as  well  as  cosmetic  disturbances.  But  these  may  follow  direct 
suture  of  a  wound  which  is  pulled  to  a  straight  line,  as  well  as  after 
undermining  and  plastic  mobilization  of  wound  edges.     On  the  other 


Fig.  25  Fig.  26 

hand,  on  the  large  surfaces  of  the  forehead  and  scalp  these  methods 
maj'  be  employed  Avith  or  without  \ariation. 

Naturally  all  large  wounds  of  the  soft  parts  on  the  head  and  face 
as  well  as  those  which  have  resulted  from  the  extirpation  of  malignant 
tumors  may  be  covered  by  plastic  flaps,  such  as  wounds  from  trauma, 
after  burns,  and  destruction  of  the  skin  as  a  result  of  tuberculosis, 
syphilis  or  noma.  Before  plastic  procedures  such  wound  siu'faces 
must  be  completely  fi-ee  of  all  diseased  and  necrotic  areas  and  the 
woimd  edges  trimmed. 

FLAP  GRAFTS 

Before  application  of  the  foregoing  methods  it  is  necessary  that 
the  wound  siu-face  should  have  an  oval,  triangular  or  rectangular 
shape.  If  these  conditions  cannot  be  fulfilled,  we  have  at  our  disposal 
another  form  of  plastic  operation,  which  consists  in  cutting  out  a  flap 
in  the  immediate  neighborhood  and  turning  it  in  on  a  pedicle  over 
the  raw  surface.  In  order  to  lay  the  flap  in  evenly  and  without  con- 
straint, various  conditions  must  be  fulfilled. 

First,  the  flap  must  be  similar  in  shape  to  the  wound  surface.  But 
since  skin  which  is  freed  from  its  bed  shrinks  considerably,  allowance 
must  be  made  in  all  directions  in  outlining  the  flap.     In  the  second 


FLAP  GRAl  rs 


101 


place,  one  must  leave  the  pedicle  of  the  flap  so  wide  that  not  only 
the  arterial  inflow,  but  the  venous  outflow  will  not  be  in  the  least 
restricted.  For  this  reason  unnecessary  cutting  of  vessels  nnist  be 
avoided  when  the  flap  is  being  made.  This  may  be  carried  out  if  one 
edge  of  the  new  formed  flap  is  the  same  as  one  edge  of  the  original 
wound  (  Fig.  27).  and  the  skin  incision  for  the  other  edge  of  the  flap 
made  in  the  direction  of  tile  vessels  and  not  across  them.  Moreover, 
in  turning  in  the  flap  on  its  nutritional  bridge  the  pedicle  should  not 
be  twisted  so  nuich  as  to  compress  the  lumuia  of  the  vessels  (Fig.  28) . 


Fic.  27 


I'^lG. 


Finally,  the  stitches  which  fix  the  flap  should  be  limited  in  nmnber 
in  order  to  avoid  danger  of  neci'osis  of  the  edge  of  the  flap  from 
sutures. 

The  secondary  wound  surface  is  covered  ovei-  \\ilh  the  aid  of  tension 
sutures,  after  undermining  the  wound  edges,  or  by  epidermal  grafts 
after  the  method  of  Thiersch. 

INDIAN    JIETPIOD 

The  modern  flap  graft  corresponds  substantially  to  the  old  Indian 
technique.  This  method  consisted  in  making  a  flap  on  the  forehead, 
with  its  nutritional  bridge  at  the  glabella,  which  resembled  in  form 
the  superflcial  tissues  of  the  nose.  ^Vftcr  separation  from  its  bed  and 
turning  on  the  broad  pedicle  the  flap  was  employed  to  reform  a  nose 
which  had  liecn  cut  off.  At  the  present  time  the  technique  of  nose 
formation  in  this  original  form  has  been  given  up  because  skin  alone 
is  not  sufficient  to  insure  a  lasting  result.  Xoses  which  are  made  of 
skin  alone  shrink  in  a  short  time  and  in  the  place  of  the  originally  suc- 
cessful feature  there  shortly  appears  a  shapeless,  disfigured  nubble. 

The  pediculated  fla])  made  out  of  the  neighboring  tissues  and 
resembling  the  wound  in  its  form  finds  its  most  favorable  application 
in  the  covering  of  large  defects  on  the  head  and  face.  I'articularly 
the  irregular  wounds  which  result  after  extirpation  of  epithelioma  in 


102  PLASTIC  OPERATIONS  ON  THE  FACE 

the  neighborhood  of  the  facial  clefts  may  be  covered  by  this  method. 
As  an  example  we  cite  the  following  case: 

A  seventy-year-old  man  had  been  blind  in  the  right  eye  since  his 
twentieth  year,  as  a  result  of  injury  with  a  steel  splinter.  The  nasal 
half  of  the  left  iipj^er  lid  extending  to  the  glabella  and  upward  over 
the  region  of  the  ej'ebrow  was  destroyed  by  an  epithelioma  the  size 
of  a  quarter.  The  conjuncti\a  and  the  eyeball  were  intact  and  the 
outer  two-thirds  of  the  lid  were  not  affected.  The  patient  had  noticed 
it  first  one  year  before. 

In  order  to  remove  the  new  growth  an  incision  was  made  through 
normal  tissue  about  l/icm.  from  its  boundary  and  it  was  freed  up  from 
its  bed  (Fig.  29,  Plate  5),  At  the  inner  corner  of  the  eye  it  was  in 
such  close  relation  to  the  bone  that  the  bone-scraper  had  to  be  used  to 
separate  it.  During  this  procediu-e  the  eyeball  was  protected  by  the 
index  finger  ( Fig.  30,  Plate  5 ) .  At  the  inner  corner  of  the  orbit 
considerable  tissue  had  to  be  removed  on  account  of  the  extension 
of  the  epithelioma,  to  insiu'e  that  no  remnants  were  left  behind. 

After  the  removal  of  the  ulcer  about  two-thirds  of  the  skin  of  the 
upper  lid  was  missing  and  about  one-third  of  the  conjunctiva.  In 
order  to  hold  the  lid  in  its  proper  position  during  the  rest  of  the  opera- 
tion and  to  protect  the  eyeball  in  the  subsequent  manipulations,  the 
lids  were  sewed  together  at  the  corner  by  a  provisional  stitch  (Fig.  31, 
Plate  5).  The  conjunctiva  of  the  upper  lid  could  be  easily  dra^vn 
inward,  and  was  attached  to  the  medial  edge  of  the  orbit  with  three 
catgut  sutures;  by  this  means  the  defect  of  the  conjunctiva  was  com- 
pletely overcome  and  a  good  l>ase  supplied  for  the  flap. 

The  large  defect  which  resulted  could  be  covered  by  a  flap  taken 
from  the  forehead  with  a  pedicle  over  the  glabella.  The  flap  was  made 
rather  large  so  that  the  inner  corner  of  the  eye  might  be  covered 
without  tension.  In  order  to  fit  it  in.  the  spur  of  skin  which  projected 
from  the  uj^per  medial  edge  of  the  defect,  as  the  result  of  the  outlining 
of  the  flap,  had  to  be  freed  from  its  base  (Fig.  32,  Plate  5).  The 
medial  edge  of  the  flap  was  then  sewed  doA\ii,  covering  in  the  lateral 
wall  of  the  nose,  the  inner  corner  of  the  lid,  and  the  mucous  membrane 
of  the  upper  lid. 

After  inidermining  the  skin  on  the  right  half  of  the  forehead  and 
the  spur  of  the  skin  already  mentioned,  the  entire  wound  surface  which 
resulted  from  the  removal  of  the  flap  could  be  closed  with  the  help  of 
three  tension  sutures,  leaving  only  a  small  fissure  (Fig.  33.  Plate  6). 
Finally,  what  was  formerly  the  right  lateral  edge  of  the  flap  was 


Krausc-Heymann-Ehrenfried. 


Tab.  5. 


C'uttinp-   and    implantatinn    of  a    pcdiculated    flap.    I. 


Edge  of  wound  in  normal  tissue 


Epithelioma 


Fig.  2Q.  Epithelioma  at  the  inner  cantiius. 


Raspatory 


Fig.  30.  Freeing  the  malignant  tissne  from  the  bone. 


Outline  of  flap 


Suture  of  conjunctiva 

Provisional  stitch  bcturcn  upper  and  lower  lids 

Fig.  31.  Showing  extent  of  wonnd  surface 
to  be  covered,  and  ontlinc  of  flap. 


Projecting 
y   spur  of  skin 


Undermining 
skin  of  forehead 


Line  of  suture 


Fig.  32.  The  freed  np  flap  has  been  turned 
and  partly  sewn  in  place. 


Rilmi iM  Comp.iiiy,  New  York. 


Krause-Heyniann-Ehrenfried. 


Tab.  6. 


Cutting-   and    im])lantati()n    of  a    ])edi dilated    flap.    II. 


Fig.  33.  The  undermined  skin  of  the  right  side  of  the  forehead  and  the 
projecting  spur  have  been  sewed  together  with  3  tension  sutures. 


Scar  along 
upper  lid 


Scar  in 

region  of 

secondary 

defect 


Scar  along  upper  lid 


Fig.  34.  Condition  after  4  weeks,  eyelids  open. 


Fig  35.  Eyeh'ds  closed. 


Rebman  Company,  New  York. 


INDIAN  METHOD  103 

united  to  the  lower  edge  of  the  loosened  spin-,  and,  likewise  without 
tension,  the  ri<>ht  lateral  e(i<>e  of  the  defect  to  the  right  corner  of  the 
flap.  The  suture  which  held  the  upper  and  lower  lid  together  was 
removed  and  a  monocular  handage  was  ajiplicd. 

The  flap  from  the  forehead  held  satisfactorily  without  necrosis  of 
the  edge  and  after  ten  days  all  stitches  were  removed.  The  tension 
suture  ])laccd  ol)li(iuely  over  the  root  of  the  nose  had  cut  through  the 
skin  somewhat,  hut  the  Assure  which  remained  had  Hllcd  in  with 
granulations. 

Four  weeks  after  the  operation  the  patient  could  fully  open  and 
close  the  lid  (Fig.  34,  and  Fig.  3.5,  Plate  6),  the  skin  of  which  in  its 
inner  thii-d  was  formed  of  the  flap,  and  the  wound  of  the  forehead  was 
completely  closed  and  covered  with  skin. 

In  this  case  the  eye  had  to  he  preserved  under  any  circumstance, 
because  the  patient  was  blind  on  the  other  side.  Even  if  this  necessity 
did  not  exist,  its  preservation  was  well  justified,  for  the  epithelioma 
had  nowhere  invaded  the  conjunctiva.  "\^.  Graefe  stated  that  in 
epithelioma  of  the  inner  corner  of  the  eye  which  invaded  the  con- 
junctiva the  eye  must  be  sacrificed.  Our  patient  suffered  no  recur- 
rence up  to  tAvo  and  one-half  years  after  the  ojjeration,  and  the  cos- 
metic results  have  remained  good. 

IXAP  GRAFTS  IN  OTIIEK  PORTIOXS  OK  THE  BODY 

Since  flap  grafts  find  their  chief  application  in  jdastic  operations 
on  other  portions  of  the  body,  it  should  he  stated  that  they  do  not 
show  the  same  disposition  to  heal  in  as  well  everywhere  as  on  the 
face.  Flaps  taken  from  the  arms  and  legs  heal  fairly  well,  but  the 
skill  of  the  shoulder,  thorax  and  abdomen  is  more  likely  to  become 
necrotic  after  transplantation,  particularly  about  the  edges.  The 
reason  for  this  probably  exists  in  the  fact  that  the  skin  of  the  face 
is  the  most  richly  ju-ovided  with  vessels,  while  the  arms  and  legs 
possess  fewer  superficial  vessels,  and  the  skin  of  the  buttocks  is  still 
more  poorly  provided  in  this  regard. 

For  this  reason  it  is  important  in  such  places  not  to  lay  out  too 
narrow  a  ])edicle,  and  not  to  interfere  with  the  nutrition  by  sutures 
Avhich  are  placed  too  closely  together.  At  the  same  time  the  loosened 
flap  should  never  be  twisted  so  far  about  its  pedicle  that  the  skin  is 
blanched  as  a  result  of  the  tension. 

In  a  seventy-year-old  man,  after  the  extirpation  of  a  recurrent 
glandular  carcinoma,  the  wound  surface  on  the  right  side  of  the  neck 


104  PLASTIC  OPERATIONS  ON  THE  FACE 

was  covered  by  laying  on  a  broad  pediculated  flap  from  the  shoulder. 
The  primary  timior  was  situated  on  the  upper  part  of  the  shell  of  the 
ear  and  had  been  removed  a  year  and  a  half  before.  In  the  meantime 
ulands  had  been  twice  removed. 

At  the  last  operation,  a  considerable  area  of  skin  and  the  upper 
half  of  the  sternomastoid  muscle  had  to  be  removed  at  the  same  time 
witli  the  infected  glands.  The  tij)  of  the  mastoid  was  chiseled  off,  and 
the  internal  jugular  vein  as  well  as  the  common  carotid  artery  was 
exposed  for  some  distance.  On  account  of  rather  profuse  venous  hem- 
orrhage, which  could  not  be  controlled  by  continued  compression,  the 
wound  was  packed  with  vioform  gauze  and  the  plastic  operation  post- 
poned for  five  days. 

The  flap  was  taken  from  below  in  the  neck  and  shoulder  region, 
since  here  there  were  no  scars  to  endanger  nutrition,  and  because  in 
addition  the  secondary  wound,  on  account  of  the  movability  of  the 
skin  in  this  region,  could  be  readily  closed  by  direct  sutin-e.  Accord- 
ingly, a  flap  was  outlined  with  a  broad  anterior  inferior  pedicle  (Fig. 
36,  Plate  7)  and  with  a  thick  layer  of  subcutaneous  tissue  was  loosened 
up  from  the  soft  parts  beneath  (Fig.  37,  Plate  7).  It  was  then 
brought  upwai-ds  and  forwards  onto  the  defect  (Fig.  38,  Plate  7)  and 
sewed  in  place  without  tension  or  distortion.  The  secondary  defect, 
after  undermining  the  wound  edges,  Avas  closed  in  a  horizontal  line  by 
direct  suture  (Fig.  39,  Plate  7). 

At  the  point  where  three  lines  of  suture  came  together,  and  accord- 
ingly considerable  danger  of  necrosis  existed,  only  the  epidermis  and 
the  uppermost  layer  of  the  corium  were  sewed  together  by  superficial 
stitches.  After  the  suture  was  completed,  no  folds  were  apparent  in 
the  skin.  Four  weeks  later  the  flap  had  healed  in  completely  without 
necrosis.  A  few  of  the  stitches  between  the  edges  of  the  secondary 
wounds  had  cut  through,  but  the  flap  closed  in  rapidly  Avith  an  appli- 
cation of  silver  nitrate.  Immediately  after  discharge,  in  spite  of  the 
wide  extirpation,  new  glands  appeared  in  the  region  of  tlie  upper 
wound  edge,  and  the  patient  died  a  year  later  from  extensive 
metastases. 

THE  ITALIAN  METHOD 

If  for  cosmetic  or  practical  reasons  the  formation  of  a  flap  from 
the  forehead  does  not  appear  feasible,  the  Italian  or  Tagliacotian 
metliod  may  find  application.  This  consists  in  dissecting  up  a  piece 
of  skin  on  the  arm  corresponding  in  size  to  the  woimd,  which  remains 


Krause-Heymann-Ehrenfried. 

Pediculatcd    I'l.i])    in    the    rci;"it)n    of  shoultlcr   and    neck 

The  tip  of  the  mastoid 
has  been  chiseled  off      Granulations      Neck  vessels 


Tab.  7. 


1  outlined,  with  base  below. 


Fig.  38.   Provisional 
implantation  of  flap 


Fig.  39.  Completion  of 

sittnre    of    flap,    and 

closure  of  secondary 

defect. 


Rclimaii  Company.  New  ^'ork. 


Krause-Hevniann-Ehren  fried. 


Italian  method  of  rhinoplast)'  I. 


Tab.  8. 


Limits  of 
the  scar 


Pedicle  with 
subcutaneous  fut 


Y'w.  40.  Scar  on  nose,  followinsr  burn. 


Fig.  41.  Flap  from  upper  arm. 


Wound  surface 

after  excision 

of  scar 


Excised 
scar  tissue 


Fig.  42.  The  excised  scar  serves  as  pattern  for 
outlining  flap 


Pedicle 


Fig.  43.  Implantation  of  flap  upon  the  nose. 


Rebinan  Company,  Nc\x'  York. 


ITALIAN  METHOD  105 

in  connection  witli  its  original  sin-i-oiindings  by  a  wide  pedicle, 
and  sewing  it  in  by  its  other  three  edges.  In  a  week  or  ten  days 
the  flap  has  nsually  healed  in  about  the  edges,  and  the  young  vessels 
which  have  grown  into  the  tiansplanted  flap  suffice  to  care  for  its 
nutrition.  The  pedicle  can  then  be  cut  through,  and  the  arm.  Avhich 
had  been  bandaged  uj)  to  the  head  during  this  time,  can  be  freed  from 
its  constrained  position. 

The  disadvantage  of  this  procednre,  in  addition  to  the  discomfort 
to  the  patient  during  the  first  ten  days,  consists  particularly  in  the 
difference  between  the  color  of  the  skin  of  the  face  and  of  the  skin 
of  the  flap.  The  skin  of  the  flap,  previously  covered  by  clothes,  is 
usually  to  be  readily  differentiated  by  its  pallor  from  its  new  surround- 
ings. Moreover,  this  lack  of  agreement  is  compensated  very  slightly 
in  the  course  of  time,  and  the  lack  of  pigmentation  of  the  transplanted 
flaj)  is  never  completely  made  up. 

The  advantage  of  the  Italian  method  consists  in  the  fact  that  the 
flap  can  be  made  of  any  desired  thickness  so  far  as  the  subcutaneous 
tissue  goes.  Also  before  transplantation  bits  of  bone  or  cartilage  may 
be  allowed  to  heal  in  under  the  flaji.  if  it  is  deemed  advisable  that  the 
new  piece  of  skin  on  the  face  shall  have  some  sujiport. 

Originally  the  Italian  method,  like  the  Indian,  was  applied  wholly 
to  rhinoplasty.  Both  had  the  same  disadvantage,  that  the  new  nose, 
which  was  composed  entirely  of  skin,  began  to  shrink  immediatelj'^ 
after  it  had  healed  in.  For  this  reason  both  methods  aie  no  longer 
used  for  this  purpose  without  modification.  But  in  their  simplicity 
they  still  serve  as  valuable  methods  for  replacing  skin  defects. 

The  following  is  the  history  of  a  case  of  transjilantation  after  the 
Italian  metliod: 

A  forty-year-old  sanitary  officer,  after  a  long  sojourn  in  the  tropics, 
developed  extensive  telangiectases  on  the  bridge  of  his  nose.  Several 
exposures  to  the  X-ray  had  resulted  in  a  burning  of  the  entire  skin  of 
the  nose  three  years  before.  The  scar  (Fig.  W,  Plate  8)  consisted  of 
shiny  tissue  under  strong  tension  showing  a  rich  development  of  vessels 
about  the  edge,  and  in  addition  to  the  cosmetic  disadvantages  it  in- 
volved a  series  of  rather  severe  symptoms.  Under  the  influence  of 
the  slightest  psychic  disturbances  and  as  a  reaction  to  the  influence 
of  sunlight,  cold  or  heat,  the  transparent  scar  epidermis  liecame  colored 
intensely  red  or  blue,  so  that  the  jjatient  suffered  extreme  anguish. 
Also  from  time  to  time  new  islands  of  telangiectasis  appeared  in  sev- 
eral places.     For  six  months  the  patient  could  not  be  persuaded  to 


106  PLASTIC  OPERATIONS  ON  THE  FACE 

undergo  an  operation,  but  gradually  the  depression  increased,  and  this 
in  conjunction  with  the  limited  outlook  for  improvement  of  the  local 
symptoms  seemed  to  justify  operation. 

The  skin  of  the  entire  nose  except  for  a  narrow  margin  had  to  be 
removed.  The  forehead  or  other  portions  of  the  face  could  not  be  used 
for  plastic  purposes  because  the  new  scar  might  give  rise  to  a  similar 
condition  of  jisychic  depression.  The  employment  of  a  free  flaj)  from 
the  arm  was  considered,  but  by  tliis  method  not  infrequently  irregu- 
larities of  pigmentation  occiu',  which  strongly  interfere  witli  the  cos- 
metic result.  There  remained,  therefore,  only  the  Italian  method. 
The  patient  himself  had  made  the  trial  for  one  day  to  see  whether 
fixation  of  the  left  arm  would  be  bearable,  with  the  flap  taken  from  the 
medial  side  of  the  upper  arm. 

The  entire  scar  was  excised  within  the  normal  skin,  so  that  the 
incision  ran  about  1  or  2  mm.  from  the  boundaries  of  the  scar.  The 
outlhied  scar  was  removed  in  one  piece  in  order  to  hold  it  as  an  exact 
model  for  the  flap.  The  cut  edges  of  the  skin  of  the  nose,  which 
remained,  were  undermined  for  about  1  mm.  in  order  that  the  plastic 
flap  (Fig.  41,  Plate  8)  could  be  sewed  in  exactly.  Naturally  the 
flap  had  to  be  outlined  in  a  considerably  larger  size  than  the  pattern, 
shice  the  skin  separated  from  its  surroundings  always  shrinks.  The 
size  of  the  excised  scar,  which  when  sjiread  out  had  the  shape  of  a 
trapezium,  were  on  the  parallel  sides  33  and  40  mm.  and  on  the 
other  sides  33  and  38  mm.  The  flap  was  made  about  one-third  larger 
and  the  pedicle  (Fig.  42,  Plate  8)  was  to  the  outer  side  of  the  arm, 
and  after  division  was  to  be  sewed  down  to  the  left  edge  of  the  defect. 

In  its  upper  half  the  flap  was  taken  away  practically  without  fat, 
because  this  jjortion  was  to  replace  the  thin  part  of  the  skin  of  the  nose, 
and  the  skin  of  the  upper  arm  contains  more  fat  than  is  desirable.  On 
the  other  hand,  the  lower  part  of  the  flap  M^as  made  thicker,  and  close 
to  the  pedicle  all  the  fat  and  subcutaneous  tissue  Avere  allowed  to 
remain.  After  outlining  the  flap,  the  arm  was  lifted  high  and  flexed 
over  the  head.  It  Avas  apparent  that  the  flap  could  be  laid  in  place 
and  sewed  in  without  twisting  the  pedicle. 

The  flap  Avas  approximated  carefully  by  sutin-es  to  the  right,  the 
upper  and  the  loAver  edges  of  the  defect  (Fig.  43,  Plate  8).  On  the 
left  margin  the  suture  naturally  could  not  take  place  because  this 
corresponded  to  the  pedicle.  The  defect  which  remained  in  the  upper 
arm  Avas  diminished  in  size  bj'  three  interrupted  sutures.  Finally  the 
arm  Avas  fixed  in  its  place  by  a  plaster  of  Paris  dressing,  enclosing  the 


Kraiise-  H  eymann-Ehrenfried. 


Tab.  9. 


Italian  method   of  rhinoplast)'.   II. 


Portion  of  fin f)  healed  in  place 


Fig.  44.  The  pedicle  is  divided  after  ten  days. 


Stihculaneous  fat, 
sliranhen  together 


Fig.  45.  Tlie  flap  is  made  tliiniier  by  removal  of 
the  fat  layer. 


Wound  edge 

Fig.  46.  The  wound  edge  is  again  freshened   up. 


Lehman  Company,  New  York. 


Krause-Heymaiin-Ehrenfried. 


Tab.  10. 


Italian  method  of  rhinoplasty.   III. 


fi 


\ 


Strip  of  fid/'  cut  away 

Fig.  47.  The  divided  pedicle  is  sewed  to  wound  margin. 


V 


:"^'^:^.- 


Fold  of  skin 
New  skin  of  nose 

Fig.  4S.  Nose  after  completion  of  suture. 


Wound 

Fig.  49.  Excision  of  the  fold. 


Suture  line 

Fig,  50.  Suture  after  excision. 


s^ 


^^^^^fp^^<*j^fl^r 


Rebman  Company,  New  York. 


Fig.  51.  Appearance  after  six  weeks. 


ITALIAX  METHOD  107 

head,  chest  and  arm.  In  order  to  jjreveiit  any  jiressure  between  areas 
of  skill  hiyiriii'  next  to  eadi  other,  and  maturation  as  the  result  of 
perspiration,  a  eonsiderahle  niiiiil)er  of  sterile  i)ads  made  of  al)sorbent 
cotton  enclosed  in  gauze  were  laid  between  tlie  arm  and  the  face,  and 
the  forearm  was  bent  so  that  its  volar  side  rested  over  the  forehead. 
In  tliis  way  tlie  flap  was  held  approximated  without  tension. 

Twelve  days  later  the  plaster  of  Paris  was  removed  Avithout  anes- 
thesia. The  transplanted  skin  had  healed  in  well  without  the  least 
necrosis  at  the  site  of  the  stitches.  In  tlie  young  scar  there  appeared 
small  injected  areas  which  marked  the  entrance  of  vessels  from  the 
surroundings.  Accordingly,  the  pedicle  was  divided,  so  that  the  flap 
from  now  on  had  to  be  noiu-ished  entirely  by  the  vessels  of  the  nose 
(Fig.  ■t4..  I'late  9).  ^^'hen  the  pecHcle  was  cut  several  hardly  visible 
vessels  bled ;  the  hemorrhage  ceased  under  light  comjiression.  Sewing 
in  of  the  new  edge  to  the  left  margin  of  the  defect  was  delayed  in 
order  to  determine  whether  or  not  there  would  be  an^'  necrosis  as  the 
result  of  the  separation  of  the  flap  from  the  arm.  A  light  sterile  dress- 
ing was  applied  and  the  jiatient  was  put  back  to  bed. 

After  ten  days,  it  being  apparent  that  the  flap  was  well  nourished, 
the  wound  on  the  left  wing  of  the  nose  was  closed.  In  order  to  attain 
the  same  favoral)le  cosmetic  result  as  had  been  obtained  upon  the 
right  side,  most  of  the  thick  fatty  layer  of  the  flap  had  to  be  trimmed 
away  before  it  was  sewed  in  (Fig.  45,  Plate  9).  This  could  be  done 
without  I'cstraint,  because  during  the  ten  days  which  had  passed,  new 
vessels  had  grown  in  from  the  under  layers.  The  flap  was  put  on  the 
stretch  and  a  knife  was  wielded  so  that  no  injury  to  the  flap  could 
result.  It  was  found  that  there  was  plenty  of  skin  to  cover  in  the 
defect.  In  order  to  make  as  fine  a  scar  as  possible,  the  left  margin  of 
the  nasal  wound,  which  had  grown  in  somewhat,  as  well  as  the  edge 
of  the  flap  itself,  were  freshened  up  again   (Fig.  46,  Plate  9). 

Tlien  followed  the  suture;  it  was  carried  out  with  the  finest  needles 
and  silk,  so  that  the  stitch  holes  lay  as  close  to  the  edge  as  possible. 
A  small  superfluity  of  skin  of  the  flap  was  removed  (Fig.  47,  Plate 
10) .  The  suture  was  com{)leted  as  far  as  the  l)ri(ige  of  the  nose.  Here 
a  fold  stood  uj)  which  had  not  been  sewed  down,  to  see  whether  the 
very  thick  flap  would  heal  down  along  the  entire  line  of  suture,  and 
to  have  a  piece  of  skin  in  connection  witli  the  rigiil  sidt'  of  the  nose 
(Fig.  48,  Plate  10)  in  ca.se  of  any  necessary  patch  work  later.  Heal- 
ing followed  so  satisfactorily  from  a  cosmetic  ])oint  of  view  that  the 
small  fold  was  removed  after  a  fortnight.     It  was  excised  by  means 


]08 


PLASTIC  OPERATIONS  ON  THE  FACE 


of  an  elipsoid  incision  and  the  skin  was  united  by  means  of  four 
stitches  (Figs.  49  and  50,  Plate  10). 

Six  weeks  after  the  operation  the  patient  was  <hscharged.  The 
end  result  was  thoroughly  satisfactory  (Fig.  .)!.  Plate  10).  The  im- 
planted portion  of  skin  on  the  nose  could  be  clearly  differentiated  in 
color  from  the  surroundings,  but  it  was  expected  that  the  pallor  might 
darken  under  the  influence  of  sunlight  and  exposure. 

TRANSPLANTATION  OF  FREE  FLAPS 

If  a  surface  wound  in  the  face  or  on  the  head  cannot  be  covered  over 
bj'  the  methods  described,  the  desired  result  may  l)e  obtained  by  means 
of  the  transplantation  of  free  flaps.  This  can  be  done  using  only 
the  uppermost  layer,  the  epidermis,  or  all  the  layers  which  make  up 
the  skin.  In  either  way  a  lasting  and  durable  result  may  be  obtained 
on  any  part  of  the  body  as  well  as  the  face. 


Fig.  rrl 
Method  of  taking  Keverdin  firiifts  from  front  of  tliijjh   ( Ehrenfried). 


EPmERMAL    TRANSPLANTATION 


Transplantation  of  the  epidermis  was  originated  by  Reverdin,  who 
established  the  method  of  "pin-point"  grafting.  According  to  this 
method  small  islets  of  epidermis  are  raised  on  the  point  of  a  needle 
and  cut  off  by  a  see-sawing  motion  with  a  sharp  knife   (Fig.  52). 


EPIDERMAL  TIIANSPLANTATION 


109 


These  are  immediately  transplanted  to  the  area  to  be  covered,  which 
may  be  fresh  or  graniilatin<r.  They  should  be  distributed  over  the 
wound  at  the  distance  of  about  \^  incli  from  each  other,  the  grafts 


KiG.  53 
Beverdin  grafts  plantcil  on  raw  surface   (%  natural  size)    ( Ehrenfried) . 

themselves  beiiiy-  about   '  s  ''i<-'li  '"  diameter   ( Fi^'.  oli).     The  basal 
or  malpighian  layer  adheres  to  the  underlying  surface  and  proliferates 


Kic.  54 

Extensive  third  degree  burn  of  ne<k.  cliest,  arm  and  axilla,  with  serious  and  protracted 
secondary  symptoms,  shows  proliferating  islands  from  Reverdin  grafts  14  days  after  their 
application.     ( Krom   Khrcnfriod  and  Cotton,  op.  cit.). 


110 


PLASTIC  OPERATIONS  ON  THE  FACE 


in  all  directions,  until  the  growing  islands  from  each  transplant  meet 
to  cover  in  the  surface  with  a  thin  hluish  epitlielium.  This  delicate 
epithelial  covering  under  proper  treatment  is  soon  converted  into  a 
durahle  skin  with  relatively  slight  contraction.  This  method  is  ap- 
phcable  to  fresh  burns  of  large  area  and  to  secreting  granulating  sur- 
faces  (Figs.  54  and  55).     Skin  enough  to  cover  the  entire  front  of 


Fig.  55 

Same  case  as  Fig.  54.  photo  taken  12  days  later.  Cliest.  neck  and  axilla  nearly  covered 
with  sound  skin.  Secondary  graft  necessary  on  arm.  All  areas  solid  9  weeks  after  burn 
received.      (From  Ehrenfried  and  Cotton,  op.  cit. ). 


the  chest  may  be  taken  from  the  front  of  one  thigh  and  leave  only 
insignificant  scars.  Inasmuch  as  the  material  is  always  taken  from  the 
patient  himself,  the  grafts  usually  "take."* 

A  method  of  transplanting  epidermis  in  larger  segments  was  orig- 
inated by  Oilier  and  developed  by  Thiersch.  It  heals  on  with  less 
assiu'ance  than  the  Reverdin  graft,  jjarticulai-ly  as  the  matei'ial  fre- 
quently has  to  be  taken  from  other  persons  than  the  patient,  but  even 
when  a  portion  of  the  transplanted  layer  fails  to  survive,  small  islets 
of  epithelium  remain  behind  and  proliferate  in  similar  fashion  to  the 
Reverdin  grafts. 

To  carry  out  the  Thiersch  method,  so  called,  a  razor  or  any  wide 
knife  made  for  this  purpose  is  employed.     The  knife  should  be  sharp. 

*For  a  fuller  discussion  of  this  method  see  Ehrenfried  and  Cotton:   Reverdin   and  other 
methods  of  skin-grafting.     Boston  Med.  and  Surg.  .Tour.,  1000,  clxi,  pp.  011-027. 


THIERSCH  METHOD  111 

Before  taking  the  grafts  it  is  moistened  in  sterile  salt  solution  in  order 
to  prevent  the  grafts  from  adhering  to  the  blade.  The  front  of  the 
thigh  usually  is  eni])l()yed.  Before  taking  the  grafts  the  skin  is  dis- 
infected by  means  of  half-strength  tincture  of  iodine. 

The  area  itself  is  flattened  and  stretched  between  the  volar  edges 
of  two  hands,  the  assistant's  above  and  the  left  hand  of  the  surgeon 
below,  or  two  small  sterile  boards  may  be  used.  The  knife  is  laid  on 
flat  and  carried  through  the  uppermost  layer  by  means  of  long  oblique 
strokes,  ^^'ith  practice  one  can  pick  up  grafts  of  considerable  size, 
but  if  this  is  not  successfully  done  a  number  of  smaller  ones  will  serve 
the  same  purpose,  without  in  any  way  influencing  the  result  of  the 
transplantation. 

The  strips  of  epidermis  are  drawn  carefully  off'  the  blade  by  fixing 
one  corner  on  the  wound  with  a  blunt  probe  and  then  carefully  draw- 
ing away  the  knife  from  under  it.  In  so  far  as  they  are  inclined  to 
curl  up  if  they  become  dry,  it  is  advisable  to  place  them  immediately 
on  cutting. 

If  after  the  transplantation  several  grafts  lap  over  each  other  or 
the  neighboring  skin,  it  is  unnecessary  to  trim  the  projecting  portion, 
for  portions  of  the  grafts  which  do  not  adhere  to  the  prepared  sur- 
face dry  up  and  fall  off  of  themselves. 

After  being  laid  in  place  the  strips  of  epidermis  are  pressed  onto  the 
surface  lightly  with  gauze  in  order  that  they  may  adhere  at  once  and 
without  formation  of  bubbles.  If  the  floor  is  completely  asejitic  or 
the  granulating  surface  dry  and  firm,  the  grafts  adhere  so  much  the 
better.  If  the  granulations  are  exuberant  and  are  secreting  profusely 
they  should  be  previously  curetted  or  otherwise  treated. 

To  cover  in  and  protect  the  transplanted  area  a  single  layer  of 
gauze  is  spread  smoothly  over  it  and  small  sponges  of  gauze  are  laid 
in  clapboard  fashion  over  this.  In  this  way  the  wound  secretion  is 
absorbed  and  at  the  same  time  light  compression  is  exerted  upon  the 
transplanted  portions.  Both  Reverdin  and  Thiersch  grafts  may  be 
held  in  place  to  advantage  by  a  single  layer  of  coarse  mull  which 
has  been  waterproofed  in  celloidin,  as  first  advised  by  Kuhn,  with 
the  edges  stuck  down  at  some  distance  from  the  wound  ])y  collodion 
or  adhesive  strips,  and  a  gauze  dressing  is  applied  over  this.  In  chang- 
ing the  dressing  only  the  gauze  is  removed  and  the  mull  is  allowed  to 
remain.  This  protects  the  grafts  and  prevents  them  from  being  torn 
away  from  their  bed  before  they  have  permanently  adhered. 

The  entire  operation  may  be  carried  out  with  little  pain  and  in 


112  PLASTIC  OPERATIONS  ON  THE  FACE 

some  cases  without  anesthesia.  But  sensitive  patients  should  be  anes- 
thetized or  the  region  from  which  the  grafts  are  to  be  taken  should 
be  cocainized.  The  wound  occasioned  by  the  removal  of  the  grafts 
is  covered  over  with  boric  ointment.  After  about  ten  days  the  grafts 
are  usually  well  adherent.  Particularly  suitable  for  epidermal  graft- 
ing are  flat  surfaces  which  cannot  be  closed  in  by  means  of  suture  of  the 
wound  edges,  and  the  method  may  be  applied  with  complete  success 
even  where  the  wound  lies  directly  upon  a  bony  surface,  such  as  the 
scalp  or  forehead. 

This  procedure,  however,  always  leaves  an  epithelial  scar  which  pos- 
sesses the  property  of  contraction  common  to  all  scars.  This  limits  the 
applicability  of  the  method ;  in  the  face,  for  instance,  contraction  will 
produce  distortion  of  the  features  and  a  cosmetic  failure. 

THE  WOLFE-KRAUSE  JIETHOD 

This  method,  originated  by  ^Volfe  for  ophthalmic  purposes  and 
developed  by  Krause,  consists,  in  contradistinction  to  the  epidermal 
graft,  in  the  employment  of  the  whole  thickness  of  the  skin,  including 
the  fat.  Since  skin  which  has  been  freed  from  its  surroundings  shows 
a  strong  disposition  to  shrink,  the  new  flaps  must  be  outlined  larger  in 
all  directions  than  the  primary  wound  surface.  Each  piece  of  skin 
shrinks  somewhat  after  it  has  been  removed,  but  it  has  no  tendency  to 
shrink  after  it  is  healed  on;  wounds  which  have  been  covered  by  whole 
thickness  grafts  do  not  contract,  in  contradistinction  to  epidermal 
grafts.  Such  grafts  when  healed  in  are  permanently  elastic  and  are 
movable  upon  the  imderlying  layer,  accordingly  they  are  more  durable 
and  are  better  able  to  resist  pressin-e  and  injury.  In  this  lies  the  ad- 
vantage over  the  technique  of  Thiersch:  the  epidermal  methods  are 
applicable  to  superficial  repair,  while  the  whole  thickness  grafts  of 
Krause  are  to  be  preferred  for  deeper  loss  of  substance. 

The  flap  is  dissected  up  without  the  underlying  fat.  But  small  bits 
of  fat  which  still  adhere  do  not  have  to  be  removed  with  scissors,  but 
may  be  allowed  to  remain.  Care  is  taken  to  avoid  the  fatty  layer 
because  without  it  the  skin  adheres  much  more  evenly  and  more 
rapidly. 

The  healing  in  of  the  flap  depends  largely  upon  its  early  adhesion 
to  the  underlying  sm'face.  The  cosmetic  result  will  be  more  satis- 
factorj^  if  the  newly  transplanted  skin  does  not  project  from  the 
wound  surface  from  the  presence  of  a  tliick  fatty  layer,  but  lies  even 
with  the  level  of  the  surrounding  skin.    The  fat  never  entirely  pre- 


WOLFE-KRAUSE  METHOD  118 

vents  healing  in,  and  after  the  transplantation  it  persists  just  like 
other  parts  of  the  skin,  the  hair,  the  ylands  and  the  elastic  tissue. 

Sometimes  at  the  heginning  or  the  end  of  the  second  week  small 
blebs  appear  in  the  epidermal  layer  of  the  flap,  which  otherwise  is 
well  adherent  to  the  wound.  If  these  are  incised  one  will  see  that  the 
epidermis  is  raised;  usually  only  local  necrosis  results,  but  large 
shreds  may  be  loosened  uj)  so  that  the  entire  flaj)  looks  like  a  weeping 
eczema.  Later  tlie  cijitheliuni  is  restored,  without  endangering  the 
vitality  of  tiie  flap,  as  the  result  of  the  proliferation  of  the  islands 
which  remain  behind  in  the  neigliborhood  of  the  sweat  and  sebaceous 
glands.  Diff'erences  in  color  bleach  out  in  the  first  few  weeks  after 
the  transplantation,  but  nevertheless  the  flap  can  be  differentiated 
through  its  stronger  pigmentation  from  the  surrounding  skin  even  in 
after  years. 

The  persistence  of  differences  in  color  is  the  only  disadvantage  of 
this  method  of  replacing  the  skin  of  the  face  with  skin  from  other 
parts  of  the  body.  Infrequently  the  transi^lanted  area  will  later  puff 
out  and  form  a  projecting  pad;  this  finds  its  explanation  in  an  irregu- 
lar trimming  of  fat  from  the  flap,  or  in  an  insufficient  preparation  of 
the  wound  surface.  Of  particular  offence  in  this  regard  are  insufficient 
hemostasis  and  scar  contraction  of  the  woimd  surface  beneath  the 
transplant. 

To  assure  the  healing  in  of  free  flaps  according  to  Krause  one 
requires  absolute  asepsis,  a  dry  technique  and  complete  hemostasis. 
The  second  requirement  can  be  accomplished  surely  and  witli  little 
difficulty  now  l)y  the  employment  of  tincture  of  iodine.  In  order  to 
fulfill  the  third  condition  the  wound  must  first  be  freed  of  all  granu- 
lations and  scar  tissue  formation  on  the  floor  and  about  the  edges,  and 
must  then  be  compressed  with  gauze  until  on  the  removal  of  the  gauze 
not  the  slightest  clot  formation  occurs.  Ligatures  should  be  com- 
jjletely  avoided  if  possible. 

In  excising  the  flap  the  danger  of  infection  may  be  limited  if,  after 
making  the  first  incision,  the  epidermis  is  seized  by  the  thumb  and 
forefinger,  and  folded  upon  itself,  so  that  in  lifting  it  wound  surface  is 
brouglit  in  contact  witli  wound  surface.  In  this  way  tlie  loosened  piece 
of  skin  is  protected  from  too  rapid  drying.  All  mechanical  injurj' 
of  the  edges  of  the  flap,  such  as  might  be  caused  by  the  pressure  of 
forceps,  is  avoided  l)y  holding  it  considerately  between  the  fingers.  In 
dissecting  off  the  skin  the  knife  l)lade  is  directed  toward  the  skin  and 
not  toward  the  substratum,  in  order  to  free  the  flap  evenly  and  with- 


114 


PLASTIC  OPERATIONS  OX  THE  FACE 


out  any  morsels  of  fat  remaining.  As  in  the  Thiersch  method,  any 
part  of  the  body  may  proj^erly  be  submitted  to  this  form  of  trans- 
plantation. However,  flaps  from  the  thigh  or  upper  arm,  particularly 
upon  the  flexor  aspect,  show  a  stronger  disposition  to  heal  on  than 
skin  from  the  buttock. 

The  free  flap  is  unfolded  and  lightly  pressed  against  the  floor  of 
the  previously  prepared  wound  until  it  adheres  throughout.  Only 
exceptionally,  for  instance  in  portions  of  the  face  which  are  very 
movable,  is  the  application  of  a  holding  suture  at  the  edge  necessary. 
Ordinarily  a  well-applied  dressing  is  sufficient  to  hold  the  rapidly  ad- 
hering flap  fast  in  its  new  situation  without  suture. 


Fig.  56 

Upper  lip.  restored  by  transplantation  of  a  free  flap  from  the  flexor  surface  of  the  upper 
arm;  photograph,  8  months  after  operation. 

The  secondary  skin  wound,  from  which  the  graft  is  taken,  is  sewed 
up  directly,  or  if  the  tension  is  too  great,  after  undermining  the 
Avound  edges  and  extirpation  of  the  fatty  layer.  Any  surface  which 
remains  uncovered  can  be  covered  in  with  epidermal  grafts. 

We  employ  free  flaps  by  preference  upon  fresh  operative  wounds 
in  the  face,  such,  for  example,  as  those  which  result  from  the  removal 
of  malignant  tumors  or  tuberculous  disease,  as  may  be  sIioami  by  the 
following  case  cited  by  Krause: 

"A  fourteen-year-old  girl  was  repeatedly  operated  on  by  my  prede- 
cessors for  ulcerative  lupus,  which  had  involved  the  greater  part  of 
the  upper  lip.  She  retm-ned  to  the  hospital  with  a  recurrence;  there 
existed  a  very  offensive  scar  ectropion  of  the  upper  lip.     On  July  8, 


WOLFE-KRAUSE  METHOD 


115 


1892,  I  removed  all  of  the  infected  portion,  which  included  practically 
the  entire  thickness  of  the  lip  down  to  the  niiicoiis  meinhrane.  and 
restored  the  defect  by  a  free  flap  taken  from  the  flexor  side  of  the 
left  iip2)er  arm,  which  after  it  had  shrunk  measured  (i  cm.  lono-  by  2  cm. 
wide.  Since  patients  comin<>-  out  of  tlie  anesthetic  continually  move 
the  lip,  the  flap  was  made  fast  by  means  of  four  silk  sutures — this  was 
the  only  case  in  which  I  had  been  induced  to  insert  stitches.  Plealing 
followed  without  incident,  the  cosmetic  result  was  very  good,  as  is 
shown  by  a  photograph  (Fig.  .56),  taken  ]March  ;30,  1898,  that  is  nine 
months  after  the  plastic  operation.  The  flap  had  not  shrunk;  it  was 
thick  and  soft." 


Fig.  57 
Photograph  hefoic  operation,  showing  extensive  lupus. 

The  following  is  another  example  of  skin  transplantation  after 
deeji-lying  and  Midcspread  destruction  of  the  skin  of  the  face  as  the 
result  of  tuberculosis,  taken  also  from  Krause: 

A  thirty-four-year-old  seamstress  suffered  since  her  seventh  year 
fi-om  lupus  of  the  face.  In  spite  of  continuous  treatment,  the  lupvis 
had  extended  until  it  involved  the  greater  part  of  the  face.  The  tip 
and  alae  of  the  nose  were  wanting,  and  no  normal  skin  was  at  hand 
for  plastic  restoration  (Fig.  .57) .  The  entire  bridge  of  the  nose  which 
Avas  affected  with  lupus  was  extirpated  down  to  the  jjcricondrium  and 
periostcun'.  as  well  as  the  neighboring  sections  of  the  cheek.  The  de- 
feet  was  immediately  covered  in  with  two  flaps  taken  from  the  volar 


116 


PLASTIC  OPERATIONS  ON  THE  FACE 


side  of  the  right  and  left  upper  arms.  Four  weeks  later  the  skin  of 
the  lip  and  in  addition  most  of  the  affected  skin  of  the  right  side 
of  the  cheek  up  to  the  ear  and  down  to  the  neck  was  extirjjated;  the 
external  maxillary  artery  was  destroyed  and  the  bleeding  controlled 
by  torsion.  A  flap  from  the  left  thigh  was  planted  over  the  defect. 
Finally,  after  a  fortnight  the  rest  of  the  infected  skin  on  the  left  cheek 
was  extirpated,  and  since  here  the  new  skin  could  not  be  turned  to 


Fig.  58 
Interniediate  stage:  photograph. 

account  for  further  plastic  purposes,  the  svn-face  was  covered  with 
Thiersch  grafts  (Fig.  .38). 

The  free  flap  which  covered  in  the  entire  nose  up  to  the  inner 
corner  of  the  eye  and  the  upper  part  of  the  cheek  at  that  time  was 
still  recognizable  from  the  scar  about  its  periphery.  This  new  skin 
was  everywhere  normal  in  appearance  and  possessed  normal  mov- 
a))ihty  upon  the  underlying  stratum ;  it  was  accordingly  employed  four 
months  later  in  tlie  form  of  two  pediculated  flaps  to  restore  the 
wings  and  tip  of  the  nose.  Avhile  the  new  defects  which  resulted  on 
the  bridge  of  the  nose  and  the  cheeks  were  covered  in  by  Thiersch 
grafts.  The  end  result  of  this  plastic  operation  was  unusually  satis- 
factory in  every  respect,  the  entire  treatment  consuming  two  and  one- 
half  years  (Fig.  59) .    Nowhere  did  lupus  nodules  appear  in  the  trans- 


WOLFE-KKAUSE  ]METHOD 


117 


planted  flaps,  but  four  small  nodules  appeared  in  different  places 
in  the  contiguous  sound  skin,  and  were  burned  out  with  the  actual 
cautery. 

Radical  excision  and  restoration  of  the  defect  by  free  flaps  is,  of 
course,  necessary  for  stubl)orn  and  recurrin*^'  cases.  Otherwise  all 
superficial  and  still  ap])arently  yount)-  cases  of  lupus  are  first  curetted. 
and  the  floor  as  well  as  the  region  of  transition  into  apijarently  healthy 


Fig.  59 
Appearance  9  months  after  transplantation;   photograph. 

skin  is  burned  out  with  the  Paquelin  cautery.  Particular  attention 
should  be  paid  to  the  pale  nodular  thickenings  in  the  deejjer  layers  of 
the  coriuni.  If  they  are  not  radically  i-enioved  with  the  curette,  recur- 
rences occur  from  these  foci.  Hemorrhage  which  does  not  stop  of 
itself  is  controlled  by  compression  with  a  pad  of  gauze,  which  may  be 
smeared  with  boric  ointment.  It  is  wonderful  how  quickly  even  ex- 
tensive sui-faces  which  have  been  treated  by  the  curette  and  the  cautery 
heal  over  after  the  scab  drops  off. 

TRANSPLANTATION    OF    FREE    FLAPS    AFTER    EXTIRPATION    OF 
MALIGNANT  (iKOWTIIS 

Free  flaps  are  also  employed  for  covering  in  wounds  of  the  face 
resulting  from  the  removal  of  malignant  tumors.  Since  these  demand 
the  most  radical  excision  of  all  suspicious  tissue,  at  times  extensive 
portions  of  the  face  without  regard  to  position  are  inchided  in  the 


118  PLASTIC  OPERATIONS  ON  THE  FACE 

woiuul  surface,  so  that  it  may  extend  over  an  entire  cheek,  or  inchide 
the  entire  npper  hp  or  chin. 

Cancer  of  the  face,  of  the  extirpation  of  which  such  wounds  are 
usually  the  result,  comes  under  om-  observation  in  two  forms:  the  flat 
idcer-like  skin  cancer  or  epithelioma,  and  the  true  carcinoma,  which 
proliferates  in  the  depths.  ^Vhile  both  these  forms  are  similar  in 
histological  characteristics,  the  flat  skin  cancer  as  well  as  the  carcinoma 
of  the  skin  taking  their  origin  from  the  flat  ejiithelium  which  is  in 
transition  to  become  horny,  clinically  they  differ  in  many  character- 
istics. The  true  carcinoma  of  the  face,  the  location  of  which  by  choice 
is  at  the  line  of  junction  of  nnicous  membrane  and  skin,  for  example 
on  the  lower  lip,  manifests  all  the  malignant  properties  of  other  can- 
cers; on  the  other  hand  the  superficial  epithelioma  grows  very  slowly 
and  lasts  for  many  years,  often  for  ten  or  more,  in  the  same  layer  of 
the  skin  and  shows  in  rare  cases  only  a  tendency  to  extend  to  the 
regional  lymph  nodes,  or  other  metastases.  In  its  centre  the  new- 
formed  tissue  in  both  forms  is  likely  to  become  necrotic  on  account  of 
the  poverty  of  circulation,  so  that  ulcers  are  formed  which  extend 
slowly  and  steadily  over  the  surface,  with  a  margin  made  up  of  an 
elevated  wall  of  carcinoma.  In  the  true  carcinoma  a  rapid  extension 
into  the  deep  tissues  goes  hand  in  hand  with  the  necrotic  ulceration, 
while  the  flat  ejiithelioma  usually  undergoes  shrinkage  and  scar  for- 
mation on  the  floor  of  the  ulcer,  as  well  as  of  one  or  more  edges. 

The  superficial  and  clinically  benign  epithelioma  may  develop  on 
any  portion  of  the  face,  but  particularly  on  the  nose  in  the  vicinity 
of  the  inner  eyelid,  and  in  places  where  the  folds  of  facial  expression 
are  particularly  impressed.  With  the  extension  of  the  ulcer  in  the 
course  of  years  considerable  sin-faces  of  skin  are  destroyed  without 
the  deep  tissue  becoming  involved.  On  the  other  hand  this  form  of 
ulcer,  which  is  the  result  of  the  activity  of  the  proliferating  ej)idermal 
carcinoma  cells,  tends  to  scar  formation  and  covering  over  Avith  epithe- 
lium, if  all  the  necrosed  tissue  has  fallen  away  and  it  has  been  pro- 
tected from  mechanical  injury.  This  process  is  such  as  to  deceive  one 
into  the  belief  that  the  idcer  has  healed,  while  in  fact  the  cells  of  the 
new  growth  are  continuing  their  development  imder  the  surface  and 
proliferating  actively.  Similarly  the  result  of  X-ray  or  radium  treat- 
ment, of  antiseptic  and  lightly  cauterant  applications,  as  well  as 
heliotherapy  and  cauterization  in  the  most  cases  is  a  temporary  and 
apparent  healing  only. 

A  wide  removal  of  an  epithelioma  by  an  incision  in  normal  tissue 


Krause-Heymann-Ehrenfried. 


Tab.  1 1 . 


Transplantation  of  a  free  flap  to  the  chin. 


Line  of  excision 
Scaneii  portion  of  tumor 

Fig.  60.  Extirpation  of  an  epithelioma. 


Sliin  flap 

Fig.  01 .  Free  flap  from  front  of  the  thigh. 


Sittnre 


Line  for  removal 
of  excess  of  flop 


Margin  of  flap 

Fig.  62.  Sutnre  of  flap  in  place. 


Scar  Tiansition  of  flap  to  normal  skin 

Fig.  63.  Condition  1 ",  years  after  operation. 


Rebnian  Company,  New  York. 


FREE  FLAPS  AFTER  KXriSIOX  OF   NEOPLASMS  119 

and  painstakino-  cleanin<>'  out  of  all  suspicious  tissue  in  the  depths  can 
alone  guarantee  a  cure  of  this  nialif^nant  disease,  as  with  other  malig- 
nant conditions.  The  following  observation  will  serve  to  show  how 
the  loss  of  tissue  may  be  provided  for  by  means  of  a  free  flap: 

In  a  forty-nine-year-old  school  teacher  a  tumor  the  size  of  a  silver 
dollar  had  deve]o])ed  during  three  years  upon  the  right  chin  furrow. 
In  the  middle  the  tumor  was  scarred  over  (Fig.  (iO,  Plate  11 ).  At  the 
perij)hery  it  consisted  of  numerous  readily  bleeding  tubercles  and 
ulcerous  excavations.  The  slowly  growing  tumor  had  never  caused 
symptoms.  Microscopic  examination  of  a  small  portion  of  the  margin 
Avhich  was  readily  remo\ed  with  forceps  showed  epithelioma. 

L'nder  general  anesthesia,  the  tumor  was  removed  by  a  rhomboid 
incision,  which  included  about  1  cm.  of  normal  tissue  (Fig.  60, 
Plate  11) .  The  skin  was  seized  with  two  toothed  clamps  at  the  upper 
corner  after  the  incision  had  been  carried  down  to  niuscle,  and  the 
entire  new  growth  with  the  underlying  fascia  was  removed.  Nowhere 
was  suspicion  aroused  that  the  epithelioma  had  penetrated  the  fascia. 
Several  layers  of  gauze  were  laid  upon  the  wound  surface  and  the 
bleeding  Avas  controlled  through  strong  pressure  while  the  flap  was 
being  cut.  The  defect  was  not  covered  by  Thiersch  grafts  because  the 
upper  edge  of  the  wound  reached  close  to  the  corner  of  the  mouth  and 
there  was  danger  that  as  a  result  of  scar  contraction  ectrojiion  of  the 
lower  lip  would  ensue.  In  order  to  prevent  this  a  flap  of  practically 
twice  the  size  of  the  defect  was  cut  from  the  anterior  thigh  (Fig.  61, 
Plate  11).  During  its  removal  the  flaj)  was  held  carefully  with  the 
fingers  by  its  epidermal  surface  so  that  the  wound  surface  came  in 
contact  only  with  the  knife,  and  with  the  same  care  it  was  carried  over 
to  the  primary  wound  on  the  chin  and  unfolded,  after  the  l)leeding 
had  been  stopped  satisfactorily  by  the  compression. 

As  the  generous  sized  flap  shrunk  to  a  marked  degree,  it  fitted  satis- 
factoi-ily  the  wound  defect  as  far  as  the  upper  edge  and  two  sides 
were  concerned;  but  below  it  oveilapped  the  wound  edge  for  several 
mm.,  and  this  su])erfluous  skin  was  removed  with  scissors.  With  regard 
for  the  continuous  activity  of  the  jaw  in  chewing,  talking,  etc.,  it 
seemed  wise  that,  in  exception  to  the  general  rule,  the  flap  should  be 
maintained  in  position  by  a  few  sutures  (Fig.  62,  Plate  11).  In  order 
to  obtain  rapid  adhesion  of  the  new  skin  to  the  base,  light  pressm-e 
was  exerted  from  the  middle  outward  toward  the  edge  by  means  of 
small  sponges.  The  woujid  of  the  thigh  after  undermining  and  mol)ili- 
zation  of  the  surrounding  skin  could  be  satisfactorily  closed  by  suture. 


120  PLASTIC  OPERATIONS  ON  THE  FACE 

Six  days  later  the  flap  was  everywhere  adherent  to  its  bed  and  the 
sutures  were  removed.  It  had  assumed  a  waxy  white  color,  but  it 
was  warm  and  dry  to  the  touch.  At  later  dressings  this  pallor  grad- 
ually was  replaced  by  a  bluish  red  shade.  Part  of  the  uppermost  layer 
of  the  epidermis  became  elevated  in  the  form  of  blebs  and  could  be 
removed,  after  incision  with  a  knife,  in  several  places.  Three  weeks 
after  the  operation  this  shedding  of  epidermis  was  over  and  the  flap 
had  healed  in  solidly,  so  that  the  patient  was  discharged.  A  year  and 
a  half  later  the  boundary  line  between  chin  and  flap  coidd  hardly  be 
recognized  and  the  skin  was  movable  upon  its  entire  bed  (Fig.  63, 
Plate  n).  No  recurrence  had  appeared  within  five  years. 


CHAPTER  8— SPFXIAL  PLASTIC  PROCEDURES 

There  is  a  great  deal  of  surgical  satisfaction  in  the  fact  that  other 
tissues  as  well  as  the  skin  allow  of  transplantation  and  remain  viahle 
in  their  new  abode.  Such  transplantation  may  be  free,  in  that  for 
example  a  ])iece  of  bone  or  fascia,  a  bit  of  fat,  or  a  slice  of  cartilage 
may  be  freed  entirely  from  its  original  surroundings  and  brought  into 
new  relations  with  tissue  in  other  places.  This  free  transplantation 
stands  in  oj)position  to  the  older  method  by  which,  for  instance,  sec- 
tions of  muscle,  l)its  of  bone  with  periosteum  attached,  or  flaps  of 
mucous  membrane  remained  in  relation  to  their  original  site  through 
nutritional  bridges  which  carried  the  circulation.  iVlso  a  combination 
of  the  free  and  of  the  pedicnlated  grafts,  such  as  the  IMuUer-Konig 
method,  by  M'hich  a  sliver  of  bone  removed  in  connection  with  a  flap 
of  skin  is  nourished  by  the  pedicle  of  the  skin  flap,  flnds  extensive 
application  in  plastic  surgery  of  the  face.  For  this  pm-pose  it  makes' 
IK)  difl'erence  whether  these  combined  flaps  are  taken  from  the  imme- 
diate neighborhood  of  the  wound  or  from  other  ])ortions  of  the  body 
after  the  Italian  method. 

By  the  aid  of  the  methods  already  described,  not  only  broad  and 
flat  surfaces  of  the  face  may  be  covered,  but  ])rominent  features  may 
be  artificially  restored,  if  destroyed  by  disease  or  injury.  By  suitable 
choice  of  methods  atul  judicious  employment  of  the  material  at  hand 
portions  of  the  face  of  complicated  structure,  such  as  the  nose,  eyelid, 
mouth  and  ear  may  be  built  up  in  satisfactory  fashion  from  a  cosmetic 
point  of  view,  and  a  total  or  j)artial  loss  may  be  agreeably  restored. 

Among  the  causes  of  the  extensive  mutilations  which  demand  plastic 
repair,  wounds  made  in  the  course  of  o])erative  removal  of  malignant 
tumors  stand  in  the  first  rank.  Xext  come  injuries,  among  which  ai-e 
particularly  to  be  considered  loss  of  tissue  l)y  l)iiriis  and  freezing, 
gunshot  wounds  and  crushing  injuries,  which  are  very  likely  to  carry 
in  their  train  the  loss  of  j)rominent  features.  In  the  third  rank  stand 
congenital  deformities  of  the  face,  particularly  of  the  lips  and  palate, 
which  demand  plastic  treatment  for  the  closure  of  clefts  which  result 
from  inconii)lctc  fetal  union  of  tissue. 

The  essential  function  of  plastic  surgery  of  the  face  consists  in 
restoring  a  mouth  bordered  by  lips,  building  up  a  nose  with  its  proper 

121 


122  SPECIAL  PLASTIC  PROCEDURES 

support,  restoring  form  to  the  shell  of  the  ear,  and  in  palliating  accept- 
ably the  loss  of  an  eye  or  one  of  its  lids.  Of  the  most  important 
surgical  diseases  and  the  operations  which  are  necessary  in  their  treat- 
ment we  shall  hi  what  follows  give  illustrative  cases;  but  it  is  im- 
practicable to  relate  here  all  the  methods  which  have  been  described 
and  recommended,  particularly  as  each  case  necessitates  variations, 
and  in  no  instance  can  a  described  procedure  be  strictly  followed. 

PLASTIC  OPERATIONS  ON  THE  LIPS:  EXTIRPATION  OF  CANCER  OF  THE  LIP 

Carcinoma  of  the  lower  lip  develops  by  predilection  at  the  point 
of  transition  from  skin  to  nnicous  membrane.  It  appears  first  as 
small  tubercles  or  jjalpable  nodules,  which  after  a  time  develop  into 
clusters  of  scabby  and  raj^idly  growing  idcers  with  irregularly  raised 
margins.  A  considerable  portion  of  the  lip  and  of  the  skin  of  the 
cheek  may  be  destroyed  by  its  growth,  and  usually  with  the  extension 
of  the  infiltration  and  of  the  idcerous  necrosis,  carcinomatous  infiltra- 
tion of  the  submental  as  well  as  of  the  lateral  glands  of  the  neck 
appears. 

So  long  as  the  carcinoma  is  reasonably  small  and  does  not  include 
more  than  two-thirds  of  the  lip,  radical  operation  l)y  means  of  a 
wedge-shaped  excision  with  direct  union  of  the  remnants  of  the  lip 
suffices,  as  the  following  case  shows.  Cleaning  out  of  all  submental 
nodes  sliould  always  be  carried  out  after  the  extirpation,  in  carcinoma 
of  the  lip  which  has  existed  for  some  time. 

A  landed  proprietor  nearly  eighty  years  old  had  had  removed, 
eight  years  before  entering  the  hospital,  an  ulcer  of  the  lower  lip  Avith 
a  hard  margin  about  the  size  of  a  penny.  During  the  course  of  a 
year  or  more  a  raw  surface  had  developed  again  in  the  region  of  the 
seal-,  ^vhich  extended  rather  rapidly.  Upon  entrance  practically  the 
entire  lower  lip  was  destroyed  by  a  carcinoma,  which  was  3  cm.  wide 
and  almost  2  cm.  high;  only  a  small  segment  of  the  lower  lip  remained 
intact  at  each  corner  (Fig.  64,  Plate  12).  In  addition,  on  either  side 
could  be  jialpated  small  and  hard  submental  nodes.  In  spite  of  the 
extent  of  the  carcinoma,  wedge-shaped  excision  was  carried  out,  since 
because  of  the  emaciation,  the  small  remnants  of  the  lower  lip  were 
readily  movable  and  serviceable;  and  on  account  of  extreme  age  the 
patient  seemed  too  weak  to  be  submitted  to  an  extensive  plastic 
operation. 

As  soon  as  the  patient  was  placed  upon  the  operating  table  severe 
collapse  developed.    For  that  reason  the  excision  was  carried  out  with- 


Kr.uise-Hcvniann-F.hrenfried 


Fab.  12. 


Wedge  excision  of  cancer    of  the  lip. 


Carchiomu 


Fig.  64.   Carcinoma   in  tlif  middle  of  the  lower  li]i. 


liurU'd  Sllflir 


Fig.  65.  Wedge  excision,  arteries  being  compressed 
by  fingers. 


Fig.  66.  Snture  of  nnicons  membrane. 


Protntdi/if; 
it/r/it'r  lip 


Fig.  67.  Skin  suture,   siiovi-ing  lack  of  Fig.  68.   The  distortion  of  the  corners  of  the 

correspondence  between  upper  and  lower  lips.      month  and  the  protnberence  of  the  npper  lip 

have  completely  disappeared  after  four  weeks. 

Ri'bm.in  Company,  New  \m\i. 


EXTIRPATION  OF  CAXCER  OF  THE  LIP  123 

out  anesthesia.  Tlie  lower  lip  was  seized  between  the  thumb  and  the 
forefinger  at  ri^ht  and  left,  in  this  way  conipressino-  the  eoronary 
artery  of  each  side  at  the  corner  of  the  mouth  ( Fi<>'.  0.5,  Plate  1'2) . 
The  operator  could  do  this  with  his  left  hand  at  the  right  side  himself, 
while  the  assistant  compressed  the  left  corner  of  the  mouth.  The  lower 
lip  was  excised  in  wedoe-shaped  fashion  with  the  knife  down  to  the 
chin  without  loss  of  blood  and  without  necessity  for  the  tying  of  a 
single  vessel.  The  mucous  membrane  of  the  mouth  and  lip  was  united 
by  seven  buried  sutures  of  fine  catgut  in  such  fashion  that  the  needle 
did  not  perforate  the  mucous  membrane,  but  penetrated  the  tissues 
just  within  it  (Fig.  66,  Plate  12).  This  was  followed  by  an  exact 
approximation  of  the  skin  of  the  chin  with  interrupted  silk.  The 
external  woimd  was  finally  covered  with  airol  paste. 

As  the  greater  part  of  the  lower  lip  was  gone,  the  two  corners  of 
the  mouth  Avere  pulled  tightly  together  when  the  remnants  of  the 
lip  were  sewed  up.  As  a  residt  the  upper  lip  was  puffed  out  so  that  it 
projected  like  a  tumor  (Fig.  67,  Plate  12).  l?ut  within  two  weeks 
this  lack  of  conformity  between  the  wide  upper  lip  and  the  narrow 
lower  lip  had  gradually  equalized  itself,  and  a  month  after  the  opera- 
tion the  patient  was  discharged  with  the  wound  healed  and  a  good 
functional  result  (Fig.  G8,  Plate  12). 

The  state  of  collapse  sufficed  to  carry  out  the  excision  without  pain; 
it  did  not  seem  expedient  to  start  local  anesthesia  for  finishing  up  the 
operation.  ^Toreover,  local  anesthesia  was  renounced  in  advance,  be- 
cause it  ordinarily  renders  difficult  the  judgment  as  to  whether  tissue 
is  suspicious  of  carcinoma  or  normal.  Xo  other  opei'ative  procedure 
could  be  considered  in  this  frail  old  man,  while  in  other  cases  cleaning 
out  of  the  submental  glands  would  have  followed  excision  of  the 
tumor. 

PLASTIC   RESTORATION   OF  THE   I.IP   rKO:\I   THE   CHEEK     (DIEFKENBACH) 

Wedge-shaped  excision  of  the  tumor  and  direct  suture  of  the  rem- 
nants of  the  lip  leads  to  a  useless  result  if  the  lip  in  entire  or  i)ractically 
entire  extent  is  destroyed  by  the  disease.  By  direct  suture  of  a  large 
defect  the  orifice  of  the  mouth  l)ecomes  too  narrow,  and  motion  of  the 
jaw  is  restricted  as  well  by  scar  contraction;  besides  the  exposure  of 
the  lower  teeth  and  gum  is  cosmetically  unsightly.  By  the  help  of 
various  operative  j)rocedui-es  these  disadvantages  may  be  avoided  and 
a  lower  lip  created  which,  without  being  loo  unattractive,  gives  a  good 
functional  result. 


124.  SPECIAL  PLASTIC  PROCEDURES 

If  the  remnants  which  remain  after  excision  of  the  tumor  do  not 
suffice  for  the  formation  of  a  useful  hp,  the  method  of  Dieffenbach, 
which  creates  a  new  hp  out  of  skin  of  the  cheek,  hned  with  mucous 
membrane,  practical  and  of  good  appearance,  really  answers  every 
jiurjiose.  By  dissecting  off  a  small  flap  of  mucous  membrane  from 
the  upper  lip  and  drawing  it  down  to  meet  the  skin  flap,  one  is 
in  a  position  to  prevent  any  considerable  scar  contraction  of  the 
orifice  of  the  mouth  from  the  corners.  Also  the  lip  which  is  newly 
made  out  of  the  whole  thickness  of  the  cheek  remains  mobile,  so  that 
solid  and  liquid  food  and  saliva  will  not  be  spilled.  A  scar  distortion 
of  the  flap  into  a  small,  tightly  stretched  bridge  of  skin  which  does 
not  reach  the  level  of  the  lower  teeth  may  be  avoided  if  the  whole- 
thickness  flap  taken  from  the  cheek  is  cut  sufficiently  high.  The  fol- 
lowing observation  will  serve  as  an  example  of  an  individual  case: 

In  a  seventy-three-year-old  letter-carrier  the  lower  lip  was  prac- 
tically completelj'  destroyed  by  carcinoma.  The  left  corner  of  the 
mouth  was  also  involved  by  the  tumor,  but  on  the  right  side  a  portion 
1  cm.  wide  remained  healthy.  Within,  the  tumor  extended  in  the 
middle  line  as  far  as  the  point  of  transition  of  mucous  membrane  of 
the  lip  to  gum.  Outside  it  extended  2^0  cm.  below  the  border  of  the 
lip  and  down  to  the  dimple  of  the  chin.  It  had  been  present  more 
than  a  year.  The  patient  had  been  accustomed  to  smoke  a  pipe  a 
good  deal. 

Since  a  row  of  enlarged  lymph  nodes  were  palpable,  these  were 
extirpated  first,  and  for  this  purpose,  with  the  head  strongly  bent 
backward,  an  incision  was  made  in  the  neck,  through  skin,  platysma 
and  fascia  in  a  line  joining  the  two  angles  of  the  jaw.  The  flap  was 
dissected  up  in  the  direction  of  the  chin,  exposing  on  each  side  the 
edge  of  the  sternomastoid  muscle  and  the  vessels  in  their  sheath.  All 
the  fat  of  the  neck,  that  surrounding  the  submaxillary  glands  and  the 
masses  along  the  vessels  which  included  the  lymph  nodes,  could  be 
removed  easily  through  this  incision  up  to  the  level  of  the  larynx. 
After  the  extirpation  of  all  suspicious  tissue  the  wound  of  the  neck 
was  sutured. 

The  plan  decided  upon  was  to  excise  the  carcinoma  in  the  form 
of  a  wedge  cut  in  the  normal  tissue  of  the  lip  and  cheek,  and  to  form 
a  new  lip  by  means  of  skin  sliding  from  the  neck.  For  this  purpose 
the  thumb  and  forefinger  of  the  assistant  seized  and  compressed  the 
inferior  coronary  artery  of  the  lip  at  each  side  in  the  pouch  of  the 
cheek.     The  entire  tumor  could  then  be  excised,  in  addition  to  the 


Krause-Hevmann-Ehrenfried. 

Plastic  restoration  of  lip  from  the  cheek  (Dieffenbach). 


Tab.  13. 


Small  flup  of 
mucous  mem- 
brant'  for  left 
corner  of  mouth 


Transverse 

incision  of 

cheek,    to  form 

lower  lip 

Carcinoma 


Wedge  excision 


Mucous  mem- 
brane of  cheek, 
to  form  border 
of  lip 


Fig.  69.  Line  of  excision  of  carcinoma 
of  lower  lip. 


Flap  for  corner 


Oblique  incision  in 
skin  of  cheek 


Fig.  70.   Completion  of  excision  and 
exposure  of  mucous  membrane  of  cheek. 


Redundant  portion  of  skin,  after 
oblique  incision  for  relief  of  tension 


Plastic  forma- 
tion of  corner 
of  mouth 


Fig.  71.  Plastic  formation  of  border  of  lip 


Mucous  mem-                                ^^^K^^^M^Ml^^^^  Folds  caused  by 

braue  for  margin                                    ^^^Kt^^^^^^^^^  pulling              of 

\        of  lip,  taken  from                                      ^^^^^^^^^^^  cheek  flap 
inside  of  cheek 

Fig.  72.  Completion  of  suture  of  lip,  formation  of  corner  of  mouth. 


Fig.  73.  Appearance  after  14  days,  mouth  open. 


Rebnian  Company,  New  York. 


RESTORATION  OF  LIP  125 

neighboriiifT  skin  of  the  chin  and  cheek  and  a  piece  of  the  npper  hp 
1  cm.  wide  (Fi^.  (59.  Phite  13).  The  incision  started  close  to  the 
ri<iht  corner  of  tiie  nioutli,  ran  tlienee  down  to  the  hoHow  of  the  chin, 
from  there  it  was  carried  to  the  left  corner  of  the  mouth  and  ended 
after  it  had  been  turned  to  a  horizontal  direction,  more  than  1  cm. 
away  from  the  orowth,  at  the  border  of  skin  and  mucous  membrane 
of  the  upper  lip.  ^Vt  the  left  corner  of  the  mouth  a  small  bit  of  mucous 
border  of  the  upper  lip  was  trimmed  off  to  be  used  later  in  coverhig 
over  the  corner. 

After  excision  of  the  tumor  the  horizontal  incision  in  the  cheek 
was  lengthened  in  the  direction  of  the  ear  for  a  distance  ^Jfoportionate 
to  the  width  of  the  excised  lower  lip,  as  this  cheek  fiaj)  was  to  form  the 
new  lip.  The  duct  of  the  parotid  gland  was  freed  by  blunt  dissection 
and  displaced  upward.  Inside  the  mouth  a  portion  of  the  mucous 
membrane  of  the  gum  at  the  chin  had  to  be  excised.  Both  inferior 
coronary  arteries  were  seized  and  tied  after  the  compression  was 
relieved. 

Next  the  border  of  the  new-formed  lip  was  made  of  the  mucous 
membrane  of  the  cheek.  A  rectangle  of  mucous  membrane  1  cm. 
high  was  cut  so  as  to  retain  its  connection  with  the  lower  flap  of  the 
cheek  ( Fig.  70.  Plate  13) ,  and  laid  down  and  sewed  upon  the  cut  edge 
of  the  lower  flap  of  the  cheek  (Fig.  71).  Enough  mucous  mem- 
brane for  this  new  mucous  border  of  the  lip  could  only  be  obtained 
by  dissecting  the  upper  part  of  the  cheek  from  its  lining  membrane 
(Fig.  70,  Plate  13).  The  duct  of  Steno  could  easily  be  displaced 
upwards  and  its  orifice  remained  in  the  mucous  membrane  of  the  upper 
flap. 

At  the  end  of  the  transverse  cheek  incision  an  incision  was  made, 
avoiding  the  duct  of  Steno,  which  ran  ob]i(]uely  toward  the  inner 
corner  of  the  eye  (Fig.  71,  Plate  13),  and  the  lower  flap  was  then 
mobilized  by  means  of  scissors  and  laspatory  from  the  alveolar 
process  of  the  lower  jaw  until  the  nuicous  membrane  of  the  edges  of 
the  wedge-shaped  defect  of  the  lower  lip  could  be  bi-ought  together 
within  the  mouth  and  sutured  with  buried  catgut.  IJy  drawing  up 
these  sutures  the  width  of  tlie  oriflcc  of  the  mouth  could  be  decreased 
until  the  mucous  membrane  of  the  remnant  of  the  lip  and  the  mucous 
membrane  of  the  cheek  flap  would  be  approximated  witliout  appre- 
cial)le  tension.  In  the  dc])t]is  of  the  pouch  behind  the  lower  lip  oidy  was 
there  a  small  surface  uncovered  witli  mucous  membrane,  and  to  this  a 
small  wick  was  laid.     Then  followed  a  careful  approximation  of  the 


-,0(5  SPECIAL  PLASTIC  PROCEDURES 

old  and  the  newly  formed  lip  borders  with  catgut  and  the  union  of 
the  skin  edges  with  silk  (Fig.  72,  Plate  13). 

After  the  orifice  of  the  mouth,  with  the  exception  of  the  left  corner, 
was  thus  completely  bordered  with  mucous  membrane,  the  flap  which 
had  been  freed  from  the  upper  lip  for  this  purpose  (Fig.  69,  Plate  13) 
could  be  employed  to  cover  in  a  corner. 

The  end  of  the  oblique  cheek  incision  was  then  united  with  the  corner 
of  the  wound  of  the  upper  lip,  and  after  a  triangular  piece  was  com- 
pletely cut  out  of  the  skin  of  the  cheek  in  the  vicinity  of  the  nose  (com- 
pare Burow's  method  [Figs.  23  and  24,  page  99] )  the  defect  of  the 
cheek  could  be  closed  by  a  linear  suture.  By  this  procedure  the  mucous 
membrane  within  the  cheek  was  pushed  into  folds,  but  without  inter- 
fering with  the  flow  of  saliva  from  Steno's  duct. 

Fifteen  days  after  the  operation,  the  wound  having  healed  by  first 
intention  (Fig.  73,  Plate  13),  the  patient  was  discharged  from  the 
hospital.  He  could  open  and  close  his  mouth  comfortably.  A  year 
and  a  half  later  the  patient  presented  himself  again;  nowhere  was 
recurrence  to  be  seen.  The  lower  lip  had  retracted  somewhat  as  a 
result  of  scar  formation,  but  the  cosmetic  and  functional  result  was 
thoroughly  satisfactory. 

In  the  plastic  formation  of  a  loAver  lip  by  this  method,  attention 
must  be  paid  to  the  following  points:  The  flap  from  the  cheek  must 
be  laid  out  high  enough  so  that  the  new-formed  lower  lip  will  not 
later  shrink  and  its  margin  be  drawn  down  below  the  level  of  the 
teeth.  Too  high  a  lower  lip  does  no  harm;  it  interferes  in  no  way  with 
the  cosmetic  result,  while  a  tightly  stretched  narrow  bridge  of  skin 
causes  disfigurement. 

The  height  of  this  flap  is  limited  by  the  course  of  the  duct  of  Steno. 
But  if  necessary  this  without  great  difficulty  may  be  freed  up  and 
sewed  with  its  orifice  into  any  satisfactory  position  in  the  mouth.  It 
is  useful  to  dissect  out  a  square  of  mucous  membrane  in  connection 
with  the  orifice,  and  to  sew  the  edges  of  this  square  into  the  mucous 
membrane  rather  than  the  orifice  of  the  duct  itself. 

Further,  it  readily  happens  that  the  newly  formed  mouth  comes 
out  too  wide,  because,  in  the  endeavor  to  prevent  scar  contraction  of 
the  orifice  of  the  mouth,  the  restitution  flap  has  been  designed  with 
too  long  an  upper  margin.  As  the  result  of  the  great  extensibility 
of  the  orbicular  muscles  of  the  mouth  the  formation  of  too  small  a 
mouth  is  not  to  be  feared  and  the  restitution  flap  may  be  cut  in  the 


HARELIP  127 

horizontal  direction  rather  narrow.  It  is  im2:)ortant  to  cover  over  the 
corners  of  the  mouth  witli  a  bridge  of  the  mucous  membrane  in  order 
to  prevent  fissures  anil  rhagades,  sucli  as  result  when  the  corners  of 
the  mouth  are  subjected  to  pull  in  opposite  directions. 

If  the  entire  margin  of  the  lip  is  lost,  small  flaps  of  mucous  mem- 
brane may  be  sjjlit  off  from  the  ends  of  the  upper  lip  so  that  only  a 
short  piece  remains  intact  in  the  middle.  These  two  fla])s  may  be 
employed  to  restore  the  liji  margin  in  the  same  way  as  the  single  flap 
was  used  in  this  case  at  the  left  corner  of  the  mouth.  This  method 
is  analogous  to  the  procedure  of  Langenbeck. 

PLASTIC  OPERATION   FOR   HARELIP 

Congenital  fissures  of  the  upper  lip  are  treated  on  the  same  prin- 
ciples as  defects  of  the  lip  created  by  operation.  But  emphasis  must 
be  laid  on  the  fact  that  in  freshening  the  edges  of  the  defect  the  sepa- 
ration of  mucous  membrane  from  skin  and  the  cutting  away  of  any 
material  whatsoever  nnist  be  done  as  economically  as  possible,  for 
surplus  tissue  may  be  used  to  advantage  in  assisting  wound  healing 
or  for  improving  the  cosmetic  effect.  In  freshening  the  edges  it  is  a 
good  ride  to  follow  closely  the  border  between  skin  and  mucous  mem- 
brane. Only  when  the  edges  of  the  defect  apjjcar  unusually  thin  in 
comparison  with  the  segments  of  the  lip  should  an  incision  for  freshen- 
ing be  carried  away  somewhat  farther  from  the  edge,  so  as  to  provide 
sufficiently  wide  wound  surfaces  to  approximate  solidly  to  each  other. 

For  cosmetic  reasons  the  freshened  jjortions  sliould  be  brought 
together  in  such  a  way  that  the  border  of  tiie  nuicous  membrane  will 
form  a  continuous  line;  and  moreover,  all  the  remnants  of  mucous 
membrane  bordering  the  defect  should  be  most  carefully  removed, 
that  later  the  resulting  linear  scar  may  not  be  distur])C(l  l)y  tlie  healing 
in  of  a  remnant  of  mucous  membrane,  which  will  create  a  disturbing 
element  on  account  of  its  color. 

Harelip  represents  an  incomplete  union  of  the  facial  anlage  sur- 
rounding the  mouth,  and  all  degrees  of  the  defect  may  be  seen.  Usu- 
ally they  are  located  on  one  side  and  not  in  the  middle  line;  for  the  pre- 
maxilla  projects,  duiing  the  period  of  devcloi)ment,  between  the  two 
fetal  lip  masses,  so  that  harelij)  occurs  as  the  result  of  incomplete 
imion  of  a  lateral  mass  with  this  middle  segment. 

Complete  harelip  rejjresents  the  highest  grade  of  this  defect  of 
development,  while  in  the  hieomplete  form  the  premaxilla  and  the 
lateral  lip  mass  have  at  least  partly  united.    In  the  former  the  fissure 


128  SPECIAT,   PLASTir  PROCEnTTRES 

reaches  into  the  nasal  cavity,  wliile  in  the  latter  a  bridge  of  tissue 
occurs  between  fissure  and  nose.  Harelip  may  be  limited  to  one  side, 
in  which  case  it  is  usually  upon  the  left,  or  it  may  be  double,  and  then 
it  is  practically  without  exception  combined  with  cleft  palate. 

Incomplete  harelip  of  slight  degree  is  treated  by  the  Nekton 
method  (Fig.  74),*  in  which  an  angular  incision  is  made  through  the 
lip  above  the  fissure,  the  edges  drawn  ajjart  and  sutured  in  a  vertical 
line  ( Fig.  75 ) . 

"A 


Fig.  74  Fig.  75 

Wide  defects  are  freshened  up  after  the  method  of  von  Grafe  with 
the  help  of  a  crescentic  incision,  and  the  wound  edges  of  the  lips  as 
well  as  the  lip  margins  are  united  by  sutures  (Fig.  76) .  This  method 
is  recommended  only  in  cases  in  which  the  lip  is  much  narrower  at  the 
fissure  than  at  the  sides.  For  in  drawing  together  the  wound  edges 
which  have  been  freshened  by  a  crescentic  incision  to  a  straight  line, 
the  lip  is  given  a  considerable  width  at  the  line  of  union. 


Fig.  76  Fig.  77  Fig.  78 

Better  results  are  afforded  by  the  method  of  IMalgaigne,  in  w^hich 
the  freshening  of  the  edges  of  the  defect  is  carried  out  in  a  straight 
line  ( Fig.  77 ) .  The  mucous  border,  however,  after  it  is  freed  from 
the  edges  of  the  fissure,  are  preserved  and,  as  in  the  method  of 
Nelaton,  are  drawn  downward  and  sewed  together  (Fig.  78).  As  a 
result  of  making  the  lateral  wound  edge  more  perpendicular  than  the 
medial,  the  difference  in  height  between  the  two  halves  is  compensated 

*These  schematic  tlrawinss  are  taken  from  the  article  on  Harelip  in  the  Real-Encyclopadie 
der  gesamten  Heilkunde,  fourth  edition,  Vol.  si.x. 


HARELIP  129 

for  in  suturiiii?.    The  iiiiJpK'  wliicli  leinains  after  the  suture  may,  if  it 
does  not  shrink  of  itself,  be  removed  after  some  weeks. 

Favorable  cosmetic  results  and  a  solid  line  of  suture  are  offered 
by  the  frequently  employed  method  of  Mirault  (  Figs.  70  and  80) .  On 
one-half  of  the  lip  the  incision  is  carried  throu<>h  the  border,  on  the 
other  it  is  oidy  cariied  down  to  the  margin  between  mucous  mem- 
brane and  skin,  so  tliat  the  mucous  border  remains  attached  by  one 
end  (Fig.  79).  This  flap  is  then  turned  down  so  that  the  other 
freshened  edge  fits  into  the  angle.     The  line  of  suture  then  corre- 


lici.  70  Fic.  SO 

sponds  with  one  edge  of  the  filtrum  (Fig.  80)  ;  the  suture  of  the 
mucous  membrane  is  run  obliquely  in  such  fashion  that  no  nipple 
results.  Division  of  the  mucous  border  should  take  place  oil  the 
larger  half  of  the  lip  because  in  the  neighborhood  of  the  split  this  is 
usually  thinner  and  runs  more  obliquely  to  the  apex  of  the  fissiu'c,  so 
that  in  suturing  only  the  least  amount  of  tension  is  created.  The 
smaller  but  stronger  remnant  of  the  lip  gives  rise  to  the  pediculated 
nmcous  membrane  flap. 

The  Mirault  method  finds  its  application  also  in  complete  harelip, 
but  in  such  cases  particular  attention  must  be  paid  to  the  deformity 
of  the  nose,  since  the  fissure  continues  into  the  nasal  cavity  and  the  ala 
of  the  nose  is  apt  to  be  flattened  out  and  shoved  over  to  one  side. 
The  rectification  of  this  half  of  the  nose  and  the  closure  of  the  hind 
wall  of  the  nasal  orifice  can  oidy  be  brought  about  if  the  upper  lij) 
is  mobilized  together  with  the  ala.  In  order  to  accomplish  this  the 
upper  lip  can  be  loosened  with  a  knife  and  periosteal  elevator  from 
the  superior  maxilla  as  far  as  the  lower  margin  of  the  orbit.  The 
hemorrliage  which  results  may  be  controlled  by  pressure.  Further 
mobilization  when  necessary  may  be  accomplished  by  the  undulating 
incision  of  Dieff'enbach,  which,  starting  from  the  fissure,  is  carried 
around  the  base  of  the  ala  up  to  its  up])er  end  and  then  transversely 
across  the  check  (Fig.  81). 


130  SPECIAL  PLASTIC  PROCEDURES 

Once  the  ala  is  well  mobilized,  a  deep  silver  wire  stitch  is  carried 
from  one  naso-labial  sulcus  to  the  other,  a  perforated  shot  is  threaded 
on  each  end,  the  alfe  compressed  between  them,  and  the  shot  squeezed 
bv  a  clamp.  If  only  one  ala  is  flattened,  the  stitch  can  come  out  on 
the  other  side  of  the  septum.  There  is  no  l)etter  method  of  correcting 
a  flattened  nose  in  all  forms  of  harelip,  but  care  must  be  taken  that  the 


Fig.  «1 


shot  does  not  cause  a  pressure  slough,  or.  in  one-sided  cases,  perforate 
the  septum.    The  stitch  should  be  out  by  the  sixth  day. 

If  the  remnants  of  the  lip  are  unusually  thin  and  under  strong 
tension,  the  zigzag  incision  of  J.  Wolfe  unites  the  edges  with  con- 
siderable assurance.  At  the  border  of  tlie  skin  and  mucous  membrane 
or  just  above  this  line  the  two  halves  of  the  lip  are  divided  horizontally 


Furrow 


Fig.  82  Fig.  83 


(Fig.  82)  and  the  sutiu'e  is  carried  out  in  a  zigzag  line.  At  the  jjoints 
Y  and  Z  (Fig.  83)  tension  sutures  may  be  inserted  through  the  entire 
thickness  of  the  lip.  On  both  edges  the  portion  of  the  mucous  border 
which  is  situated  at  the  apex  of  the  fissure  is  sacrificed,  while  the 
remaining  portion  is  emploj'ed  for  the  formation  of  the  new  mucous 
border. 
"  Double  harelip  is  treated  on  the  same  principles  as  single.     The 


Krause-Heymann-Ehrenfried. 


Projecting  premaxiUa 


Tab.  14. 


Operation  for  double  hare  lip. 


Exposed  voniei 

Mucous  membrane^ 
covering  the  vomer 


Cleft  palate 


Fig.  84.  Exposure  and  division 
of  vomer. 


,  Suture  of  mu- 
cous membrane 

Superior 

maxilla 


PremaxiUa 


Stitch  holding 
two  portions   of 
vomer  in  place 


#% 


Fig.  85.  The  anterior  lial: 
displaced  backward. 


Fig.  86.  Formation  of  lip  flaps. 


Fig.  87.  Sewing  in  place 
and  freshening  the  premaxiUa. 


Fig.  88.  Tension  incision  of  Dieffenbach. 


Stitch 

supporting  ala 

of  nose 


Suture  line 


Fig.  89.  First  holding  stitch 
placed  in  centre  of   npper  lip. 


.;^;^^C 


Fig.  QO.  Suture  of  lip. 


Prent  axilla 


^ 


Fig.  91.  Suture  of  lip  and  cheek.  Fig.  92.  Suture  of  iiuier  side  of  li]i.         Fig.  93.  Scar  8  days  after  operation. 

Rebman  Company,  New  \'ork. 


HARELIP  131 

choice  of  operative  procedures  depends  entirely  upon  the  size  and 
width  of  the  defect,  and  still  more  upon  the  situation  of  the  prcniaxilla, 
which  projects  in  the  middle.  This  clement  offers  severe  diHicidties 
if  it  projects  beyond  the  level  of  the  lip  sva-face,  as  usually  occurs 
in  these  cases.  The  necessary  replacement  of  the  premaxilla  is  carried 
out  on  the  principles  devised  by  Bardeleben,  through  a  subperiosteal 
division  or  we(li>e-shapcd  resection  of  the  vomer.  Kven  if  it  is  deter- 
mined that  the  replaced  premaxilla  does  not  enter  into  solid  union 
with  the  two  halves  of  the  upper  jaw,  nevertheless  its  maintenance 
in  this  position  is  important  for  the  cosmetic  and  functional  results. 
For  in  the  first  place  if  the  premaxilla  is  retained  the  two  halves  of 
the  alveolar  process  cannot  fall  tooether  later  on,  and  in  the  second 
place  the  arc  of  tlie  upper  lip  maintains  its  natural  prominence  in  the 
middle  line. 

The  following  case  will  serve  as  an  example  of  an  operation  for 
double  harelip  and  replacement  of  the  premaxilla: 

A  ten-weeks-old  girl  baby  was  born  with  double  harelip,  a  markedly 
projecthig  premaxilla  and  a  cleft  of  the  soft  and  hard  palates.  The 
vomer  was  displaced  somewhat  to  the  right,  so  that  the  cleft  in  the 
hard  palate  was  particularh'  definite  on  the  left  side  and  on  the  right 
it  a])pcared  much  smaller. 

The  harelip  was  closed  first.  For  this  purpose  the  premaxilla  was 
replaced  backwards  after  the  method  of  Bardeleben:  After  the  muco- 
periosteal  covering  of  the  lower  edge  of  the  vomer,  which  projected 
into  the  cleft,  was  incised  longitudinally  (Fig.  8-1.  Plate  14),  it  was 
freed  up  on  both  sides  by  means  of  the  jieriosteal  elevator,  and  the 
vomer  was  di\ided  with  bone  cutting  forceps.  This  allowed  the  pre- 
maxilla to  be  replaced  by  light  pressure,  causing  the  two  bony  seg- 
ments of  the  divided  vomer  to  overlap  (Fig.  8.5,  Plate  14) .  In  order 
to  hold  the  vomer  iti  its  replaced  position  a  catgut  suture  was  carried 
with  a  strong  needle  through  the  overlapping  segments  and  tied;  the 
mucoperiosteal  covering  was  then  completely  closed  (Fig.  86, 
Plate  14). 

Freshening  of  the  edges  of  the  premaxilla  and  of  the  fissures  in 
the  lip  followed  as  the  second  step  in  the  operation.  This  began  with 
the  formation  of  a  flap  of  the  mucous  membrane  of  the  lip  on  each 
side  by  means  of  a  transverse  incision  several  mm.  long  carried  above 
the  red  border  through  the  entire  thickness  of  the  lip  (Fig.  86, 
Plate  14).  This  was  followed  by  freshening  of  the  lower  border  of 
the  premaxilla  where  it  was  covered  with  mucous  membrane,  and  here 


132  SPECIAL  PLASTIC  PROCEDURES 

the  mucous  membrane  was  separated  on  a  level  to  avoid  injury  to  the 
tooth  buds  (Fig.  87,  Plate  14).  Tlie  hemorrhage  which  resulted  was 
controlled  by  short  compression. 

In  an  attempt  to  close  the  cleft  by  approximation  of  the  freshened 
edges  the  tension  on  the  two  halves  of  the  lip  appeared  too  great, 
and  in  spite  of  the  suture  of  the  vomer,  the  premaxilla  sprung  back 
into  its  original  position.  In  order  to  overcome  this  it  was  held  in 
place  by  a  suture  on  each  side,  uniting  its  mucous  membrane  with  that 
of  the  alveolar  process  (Fig.  87,  Plate  14) .  To  overcome  the  tension, 
Dieffenbach's  incision  was  made,  separating  the  ala  by  a  crescentic 
incision,  and  carrying  a  transverse  incision  through  the  cheek  (Fig.  88, 
Plate  14). 

In  this  way  the  upper  part  of  the  remnants  of  the  lip  were  rendered 
freely  movable,  so  that  suture  of  the  mucous  membrane  of  the  lip  on 
the  further  side  could  be  begun.  The  first  stitch,  which  was  placed  at 
the  tips  of  the  mucous  membrane  flaps  (Fig.  89),  was  left  long  after 
tj^ing,  to  be  used  as  a  hold  in  introducing  the  other  stitches.  Approxi- 
mation could  be  made  without  distortion  until  a  sufficient  height  of 
lip  was  obtained  (Fig.  90,  Plate  14).  This  left  the  flattening  out 
of  the  alse,  which  would  interfere  badly  witli  the  later  cosmetic  result. 
It  was  accordingly  corrected  on  each  side  by  means  of  a  deep-lying 
suture,  which  was  jilaced  transversely  from  just  behind  the  nasal 
orifice  to  the  apex  of  the  division  between  premaxilla  and  ala 
(Fig.  90,  Plate  14) .  By  the  suture  of  the  previously  closed  upper  lip 
to  the  cheek  (Fig.  91,  Plate  14)  which  now  followed,  a  permanently 
good  position  of  the  nasal  orifices  was  obtained. 

The  operation  ended  with  sutiu'e  of  the  inner  surface  of  the  mucous 
membrane  of  the  lip  (Fig.  92,  Plate  14).  It  was  carried  out  by 
everting  it  by  pulhng  on  the  ends  of  the  suture  which  had  been  left 
long,  which  made  the  sewing  up  of  the  edges  of  the  defect  on  the 
premaxilla  as  well  as  the  lip  easj'  of  performance. 

No  dressing  was  applied.  Eight  days  later  the  freshened  surfaces 
had  healed  together  so  that  the  sutures  could  be  removed  (Fig.  93, 
Plate  14) .  On  discharge  ten  days  after  operation  the  child  had  gained 
over  three  ounces  in  weight. 

The  suture  of  the  cleft  palate  was  postponed  until  later. 

Since  harelip  involves  considerable  danger  for  the  child  during  the 
first  months  of  life  and  tlie  mortality  without  operation  is  high,  the 
question  arises  when  such  a  child  should  be  operated  upon.     The  de- 


HARELIP  133 

termination  of  this  question  depends  upon  whether  it  is  strong  enough 
to  stand  the  limited  hut  .serious  loss  of  hlood  during  the  operation,  and 
the  interferenee  with  nutrition  whieh  results  during  the  first  few  days 
after  the  operation.  The  first  danger  may  be  met  by  unremitting 
compression  on  the  two  halves  of  the  lip  during  the  operation;  the 
other  by  accustoming  the  child  beforehand  to  taking  milk  with  a  spoon. 
The  interference  with  nursing  and  drinking  endangers  the  child  with 
harelip  so  seriously  in  its  nutrition  that  it  should  be  operated  upon 
if  possible  within  the  first  few  days  after  birth. 

The  danger  of  the  operation  grows  less  as  the  child  grows  older, 
but  it  is  a  mistake  to  believe  that  in  later  years  the  conditions  are  more 
favorable  for  plastic  operation  than  in  the  early  days.  It  is  true  that 
the  plastic  material  increases  in  amount  with  age,  but  the  defect  in- 
creases proportionately,  and  the  gradual  atrophy  of  the  edges  of  the 
defect  and  retraction  of  the  remnants  of  the  lip  easily  renders  difficult 
a  good  cosmetic  result.  Also  in  late  cases  the  soft  parts  and  bones  lose 
their  adaptability,  so  that  in  spite  of  a  successfid  plastic  operation  the 
lines  of  expression  are  apt  to  continue  distorted.  In  any  case  nursing 
children  with  nasal  or  bronchial  catarrh,  intestinal  catarrh,  or  stoma- 
titis should  be  opei-ated  on  only  after  recovery  from  these  diseases. 
Also  nurslings  should  be  guarded  from  any  change  in  milk  before 
the  operation.  A  child  brought  into  the  hospital  shoidd  be  given  a  few 
days  to  see  if  the  change  in  nourishment  causes  any  trouble.  Finally, 
no  attempt  should  l)e  made  to  disinfect  the  mouth.  The  operative  field 
does  not  allow  of  asepsis,  and  the  stomach  and  intestines  are  injured 
by  antiseptic  agents,  while  the  useful  activity  of  the  mucous  membrane 
of  the  mouth  is  diminished  or  entirely  lost. 

Usually  no  dressing  is  necessary.  If  the  freshened  wound  is  to  be 
protected  from  soiling  with  milk  or  nasal  mucus,  the  rapidly  harden- 
ing airol  paste  may  be  painted  along  the  line  of  suture.  If  the  suture 
threatens  to  give  way  during  crying,  a  strip  of  adhesive  cut  in  the 
shajie  of  a  dumbbell  or  butterfly,  with  wide  ends  and  narrow  in  the 
middle,  will  lessen  the  tension.  The  broad  surface  is  stuck  down  on 
the  skin  of  the  cheek  on  either  side  while  the  cheeks  are  brought 
together  so  as  to  pucker  the  lip;  the  narrow  bridge  in  the  middle 
lies  over  the  region  of  the  suture  and  is  kept  from  contact  with  it  by 
means  of  a  small  bit  of  gauze,  which  is  laid  under  the  plaster.  Or  the 
same  thing  may  be  done  with  crepe  lisse  and  collodion.  The  wound 
must  be  protected  from  the  hands  of  the  child  by  enclosing  them  in 
cylinders  of  pasteboard  and  bandaging  them  down  to  the  body. 


1.34  SPECIAL  PLASTIC  PROCEDURES 

If  the  tension  is  slight,  the  wound,  as  is  usual  in  small  children, 
heals  rajjidly,  and  after  eight  days  the  sutures  can  be  removed.  But 
if  they  cut  through  before  that  they  should  be  allowed  to  remain 
nevertheless  until  they  become  entirely  loose;  for  the  small  bridges 
of  the  skin  between  the  sutures  serve  as  satisfactory  sources  of  scar 
formation  if  the  tension  increases.  Small  fistulie  or  gaps  may  be 
closed  later  by  secondary  operation. 

PLASTIC  CLOSURE  OF  CLEFT  PALATE 

Double  harelip  as  well  as  marked  cases  which  are  limited  to  one  side 
are  usually  associated  with  congenital  cleft  of  the  hard  and  soft  palate. 
Since  both  these  deformities  originate  in  the  same  way  and  also  have 
much  in  common  in  the  way  of  operative  treatment,  we  shall  give 
consideration  here  to  the  more  important  points  in  the  treatment  of 
cleft  palate. 

If  the  cleft  extends  from  the  lips  through  the  hard  and  soft  palates, 
there  residts  a  complete  split  of  the  upper  jaw,  which  is  called 
uranoschisis.  Since  the  floor  of  the  nasal  cavity  and  roof  of  the  mouth 
coincide,  the  two  cavities  are  thrown  into  one.  The  lower  edge  of  the 
vomer  projects  in  such  cases  into  the  common  oro-nasal  cavity,  and 
since  it  divides  the  cavity  into  two  portions,  one  speaks  of  such  a  case 
as  a  double  cleft  palate.  This  is  in  contradistinction  to  the  clefts  which 
occur  to  one  side  of  the  vomer.  These  result  from  the  fact  that  the 
lower  edge  of  the  vomer  has  become  adherent  on  one  side  to  the 
premaxilla  and  the  half  of  the  palate  while  this  closure  has  not 
occurred  upon  the  other  side. 

If  the  cleft  is  limited  to  the  roof  of  the  mouth,  that  is  to  say  the 
soft  palate  or  the  hard  and  soft  palate  together  remain  ununited,  but 
union  of  the  lips,  the  premaxilla,  and  the  alveolar  process  has  taken 
place,  such  a  deformity  is  called  a  simple  cleft  palate. 

Cleft  palate,  like  harelip,  may  have  a  serious  influence  upon  the 
vitality  of  the  child.  This  is  particularly  the  case  if  the  two  deformi- 
ties occur  together.  The  special  danger  lies  in  the  interference  with 
nutrition  which  results  from  the  fact  that  the  infants  are  not  in  con- 
dition to  suck  and  swallow  milk  in  sufficient  quantities.  In  swallow- 
ing a  portion  always  flows  back  through  the  nose.  Also  such  infants 
are  exposed  to  gastric  and  intestinal  diseases  and  bronchitis  as  the 
result  of  lack  of  closure  of  the  lips.  Plastic  closure  of  the  cleft 
jnilate  may  therefore  be  considered,  like  the  operation  for  harelip, 
as  a  life-saving  procedure. 


Krause-Heymiinti-Ehrenfried. 


Tab.  15. 


Operation  for  cleft  palate  after  B.  v.  Langenbeck.  I. 


Preliminary  extirpation  of  hypertrophied  tonsils. 


Cleft  palate 


Tonsils 


Fig.  94.  Cleft  palate  with  hypertrophied  tonsils. 


Right  tonsil 


Left  tonsil 


h"ig.  Q5.  Extirpation  of  the  right  tonsil 


Probe  pointed  knife  wrapped  with  gauze 

Fig.  90.  Extirpation  of  the  left  tonsil. 


Rebman  Company,  New  York. 


CLEFT  PALATE  135 

If  these  two  defoniiities  occur  together  it  is  advisable  first  and  as 
early  as  possible  to  repair  the  harelip,  and  later  to  close  the  cleft 
palate.  There  are  many  grounds  for  this  practice.  In  the  first  place 
tlie  operation  of  repairing  cleft  palate  is  the  more  extensi\e  jiroccdure, 
and  operative  injury  and  manipulation  within  the  mouth  in  the  first 
year  of  life  is  attended  with  possibilities  of  danger  to  the  gastro- 
intestinal track.  In  the  second  place,  at  a  later  date  one  can  succeed 
better  in  closing  the  cleft,  because  the  material  available  for  plastic 
closure  increases  with  the  age,  and  the  stability  of  the  suture  is  in- 
creased in  proportion.  Finally,  the  possibility  remains  that  the  cleft 
may  spontaneously  lessen  in  width;  this  is  particular^  apt  to  be  the 
case  if  the  harelip  has  been  previously  closed  and  the  projecting  pre- 
maxilla  replaced.  Also  in  the  first  and  second  years  union  of  the 
premaxilla  with  the  alveolar  process  of  one  side  may  take  place  with- 
out surgical  interference. 

But  the  cleft  should  be  operated  upon  also  as  early  as  practicable, 
and  the  closure  should  not  be  jjut  off,  as  some  of  the  older  authors 
recommend,  to  the  middle  or  end  of  the  first  decade.  The  outlook 
for  a  successful  closure  is  better  in  infancy  than  in  later  years,  and  the 
difficult}'  of  operation  and  the  loss  of  blood  need  not  necessarily  be 
greater.  Helbing*  regards  as  of  greatest  advantage  the  functional 
result,  since  early  operated  children  learn  to  speak  clearly  in  a  way 
which  is  hardly  to  be  difl'erentiated  from  the  normal.  And  if  the  cleft 
palate  is  not  combined  with  a  harelip,  it  should  be  operated  upon 
early,  because  many  of  the  unoperated  nurslings  die  in  the  first  year 
from  the  disturbances  which  result. 

Plastic  closure  of  the  cleft  palate  is  carried  out  after  the  method 
of  Langenbeck.  It  consists  in  three  steps:  loosening  of  the  muco- 
periosteal  covering  of  both  sides  of  the  hard  palate,  freshening  the 
edges  of  the  cleft,  and  the  suture.  The  following  case  will  serve  as 
an  example: 

In  a  seven-year-old  boy  an  attempt  was  made  by  others  in  the 
second  year  to  close  a  cleft  palate  by  operation.  A  few  scars  present 
in  the  neighborhood  of  the  edge  of  the  alveolar  process  originated  in 
this  procedure.  Since  both  tonsils  were  hypertrophicd  (Fig.  94, 
Plate  1.))  and  wej-e  covered  with  white  plugs,  in  order  that  they  might 
not  infect  the  sutures  they  were  seized  with  tonsil  forceps  (Fig.  95, 
Plate  1;5)  and  excised  by  means  of  a  knife,  the  blade  of  which  was 
wra|)ped  in  gauze  up  to  the  middle  (Fig.  96,  Plate  15).     This  could 

•Hcilin.  klin.  Woili..  1909,  Nr.  39. 


136  SPECIAL  PLASTIC  PROCEni'RES 

be  done  because  the  two  halves  of  the  uvula  were  well  formed  and 
tonsil  tissue  did  not  seem  to  be  needed  for  plastic  restoration  of  the 
uvula.  Bleeding  was  light,  and  it  ceased  after  a  few  minutes  under 
pressure. 

The  operation  itself  was  carried  out  with  the  head  hanging  over 
the  end  of  the  table,  in  the  Rose  position  (Fig.  97,  Plate  16).  In 
order  to  keep  the  mouth  open  a  Whitehead  gag  was  introduced.  First 
a  linear  incision  was  made  on  each  side  close  to  the  alveolar  process 
of  the  upper  jaw,  from  the  posterior  margin  of  the  hard  palate  for- 
ward through  the  muco-periosteal  layer  down  to  bone  (Fig.  98, 
Plate  16) .  Through  these  lateral  incisions  the  nnico-periosteal  cover- 
ing of  the  hard  palate  was  loosened  up  to  the  middle  line  with  a  curved 
periosteal  elevator.  This  freeing  up  of  mueo-periosteum  was  carried 
out  in  the  same  way  at  the  posterior  margin  of  the  palatal  bone  and 
at  the  hamular  process.  Since  mucous  membrane  and  periosteum  are 
here  very  closely  adherent,  they  must  be  torn  from  the  bone  with 
considerable  force.  In  order  to  overcojne  the  tension  sufficiently  to 
mobilize  them  to  the  middle  hne,  a  trial  demonstrated  that  the  edges 
could  be  brought  together  so  as  to  overlap  several  millimeters  without 
tension.  The  hemorrhage  from  the  lateral  incisions  was  controlled 
by  sponging  and  pressure. 

After  this  preparatory  freeing  of  the  flaps,  the  edges  of  the  clefts 
were  pared  in  the  following  manner:  A  small  double-edged  knife  (a 
cataract  knife  will  do  very  well)  was  introduced  in  the  apex  of  the 
defect  (Fig.  99,  Plate  16)  in  the  neighborhood  of  the  alveolar  process, 
directed  obliquely  inward,  and  the  border  was  removed  in  one  piece 
from  before  backward  through  the  soft  palate  and  the  tip  of  the 


Fig.  1115 


uvula  (Fig.  100,  Plate  16).  As  a  result  of  the  obliquity  of  the  knife, 
more  was  taken  from  the  oral  surface  of  the  mucous  membrane  than 
from  the  nasal.    In  that  wav  two  wide  freshened  wound  surfaces  were 


Krause-Heyraann-Ehrenfried. 


Tab.  16. 


Operation  lor   clclt  palate  after  B.  v.  Langenbeck.  II. 

Plastic  of  Palate. 


Exposing 

the  hara 

palate 


Fig.  97.   Operation  with   head   hanging  over 
edge  of  table  (Rose  position). 


Two  edged  knife 


Fig.  Q8.  Freeing  up  of  muco- 
periosteal  layer. 


Obliquely 
freshened 
wound  edge 


Fig.  99.  Freshening  of  the 
edges  of  cleft. 


Separated 
margin 


Suture  line 


Holding  stitch 


'  /  iilernl 


j    tension 


Fig.  100.  Removal  of  margin 
of  cleft. 


Fig.  101.  Completion  of 
suture  of  cleft. 


Fig.  102.  Suture  of  uvula. 


Nasal  surface  of  nvnia 

/ 


Fig.  103.   Suture  of  nasal 
surface. 


Gauze  packing 


Fig.  104.  Packing  the  tension 
incisions. 


Rebiiiaii  Comp.iiiy,  New  York. 


CLEFT  PALATE 


137 


created,  which  was  particularly  desirable  for  lasting  approximation  in 
view  of  the  scars  which  remained  behind  from  the  old  operation. 

This  was  followed  by  the  suture  of  the  two  halves  of  the  palate.  A 
tension  suture  to  hold  the  wound  svn-faces  together  was  not  necessary, 
and  the  suture  could  be  laid  close  to  the  wound  edges  (Fig.  101, 
Plate  16).  A  part  of  the  stitches  were  introduced  so  as  not  to  per- 
forate the  mucous  membrane  of  the  nose  (Fig.  10.5).  Between  these 
sutures  others  were  laid  which  included  the  nasal  mucous  membrane 


Fig.  100 


as  well  as  that  of  the  mouth,  but  always  close  to  the  wound  edge. 
None  of  these  sutures  were  tied  at  once,  but  to  avoid  snarling  and 
to  make  it  easy  to  tie  them  later,  they  were  knotted  at  some  distance 
from  the  wound  ( Fig.  106) .  The  sutures  were  placed  by  a  stab  needle 
with  a  curve  like  a  fishhook  (Fig.  107),  but  an  ordinary  small  curved 
needle  on  a  holder  will  do  as  well.  By  this  method  of  alternating 
sutures  it  is  easy  to  bring  the  wound  edges  together  exactly,  and  where 
the  mucous  membrane  has  a  tendency  to  roll  inward,  it  may  be  drawn 
out  with  tooth  forceps  at  the 
mouth. 


moment  of  tying  and  turned  into  the 


138  SPECIAL  PLASTIC  PROCEDURES 

Finally  the  two  halves  of  the  uvula  were  carefully  united  and  the 
last  suture  at  the  tip  of  the  uvula  (Fig.  102.  Plate  16)  on  the  oral 
aspect  was  left  long,  so  that  by  pulling  on  it  the  nasal  aspect  of  the 
uvula  could  be  made  approachable  with  the  needle.  It  was  brought 
together  here  by  means  of  two  sutures  (Fig.  103,  Plate  16). 

In  each  of  the  lateral  incisions  in  the  base  of  the  alveolar  processes 
a  short  piece  of  vioform  gauze  tape  was  introduced  (Fig.  104, 
Plate  16)    and  allowed  to  remain  three  days. 


( 


Fig.  107 

On  the  fourth  day  after  operation  the  boj^  developed  scarlet  fever. 
He  vomited  violently  several  times  and  as  a  result  some  of  the  stitches 
pulled  through,  so  that  the  line  of  suture  gaped  for  about  1  cm.  The 
rest  of  the  line  healed  smoothly  and  the  closure  of  the  small  ojjenmg 
in  the  middle  was  postponed  until  later. 

Similar  small  residual  operations  are  necessary  in  many  cases  of 
cleft  palate  as  well  as  in  harelip,  and  it  usually  suffices  in  such  an 
event  to  freshen  the  edge  of  the  defect  anew  and  to  sew  it  up. 

The  functional  result  in  later  years  in  children  who  are  operated 
upon  does  not  always  correspond  Avith  the  surgical  result.  In  spite 
of  the  fact  that  a  satisfactory  partition  has  been  created  between  the 
mouth  and  the  nasal  cavity  from  an  anatomical  point  of  view,  never- 
theless in  manj'^  cases  a  definite  nasal  quality  remains  in  the  speech. 
This  is  due  to  defective  mobility  of  the  soft  palate,  if,  for  instance, 
it  is  pulled  backwards  against  the  posterior  wall  of  the  pharynx  by  a 
stiff  band,  or  if  the  length  of  the  new  ly  formed  uvula  does  not  suffice, 
or  if  it  is  not  compact  enough  to  lay  itself  against  the  posterior  wall 
of  the  pharynx  in  the  formation  of  certain  sounds.  But  usually  by 
means  of  systematic  exercises  in  expression  and  respiration  the 
patients  can  learn  to  improve  their  enunciation.  The  best  prophy- 
lactic against  such  speech  defects  is  the  earliest  possible  operation. 

From  the  point  of  view  of  the  dentist  even  the  widest  clefts  may 
be  closed  by  means  of  hard  rubber  ])rothetic  appliances.  Not  only  is 
the  result  often  not  inferior  to  the  operative  result,  but  it  may  excel 
it.    But  a  natural  separation  of  the  mouth  from  the  nasal  cavity  is  to 


Krause-Heymaiin-Elirenfried. 


Tab.  17. 


Plastic  closure   of  a   cleft  ala  nasi. 


Fissure 


Fig.  lOS.  Incomplete  cleft  right  ala  of  nose. 


-&^ 


Apex  of  cleft 

Fig.  109.  Freeing  margin  of  cleft. 


Rhomboid  defect  with  freshened  wound  edges 
Fig.  110.  Tlie  separated  margin  drawn  downwards. 


Fig. 


Suture  line 

Vertical  suture  of  freshened  wound  edges. 


Rebman  Company,  New  York. 


CLEFT  PALATE  139 

be  preferred  over  any  prothetic;  and  moreover,  ol)turators  cannot 
be  applied  until  after  the  molar  teeth  have  a])peared.  Nevertheless, 
there  are  cases  in  which  recourse  must  be  liad  to  such  appliances. 
Among  the  cases  to  which  this  treatment  can  properly  be  applied  are 
the  widely  gaping  clefts  with  steep  and  narrow  palatal  segments,  as 
well  as  wide  clefts  with  badly  scarred  surfaces,  such  as  result  from 
unsuccessful  attempts  at  operation,  and  in  addition  all  cases  in  which 
in  spite  of  successfvd  operation  the  soft  palate  and  the  uvida  are  too 
small  or  do  not  function  properly  to  be  of  use. 

In  order  to  protect  even  the  widest  clefts  from  the  use  of  prothetics, 
Helbing*  has  attempted  to  diminish  the  cleft  before  carrying  out  the 
operation  itself.  He  accomplishes  this  by  chisehng  through  the  zygo- 
matic process  of  the  upper  jaw  at  the  level  of  the  second  premolar 
tooth  from  within  the  mouth,  and  in  that  way  to  free  the  upper  jaw 
from  its  bony  union  with  the  zygomatic  process,  and  further  by  ap- 
proaching the  mobilized  halves  of  the  palatal  process  of  the  upper  jaw 
by  means  of  metal  plates,  which  fit  about  the  alveolar  arch  and  are 
bound  together  across  the  mouth  with  wire.  The  wire  is  drawn 
through  the  alveolar  process  at  the  level  of  the  first  premolar  tooth, 
and  it  is  drawn  back  again  posteriorly  in  the  region  of  the  last  molar 
through  the  alveolar  process  on  the  nasal  surface  of  the  palatal  bone, 
and  is  tied  over  lead  buttons.  This  is  similar  to  the  method  of  Brophy 
in  new-born  children.  The  result  consists  in  a  gradual  diminution 
of  the  cleft,  which  proceeds  so  far  that  even  very  small  palatal  seg- 
ments may  be  employed  for  plastic  closure  according  to  the  method 
of  Langenbeck. 

PI,ASTIC  OPKRATIONS  ON  THE  NOSE 

Plastic  operations  for  the  purpose  of  restoring  portions  of  the  nose 
and  re-establisl)ing  its  outer  form  may  become  necessary  for  the 
closure  of  congenital  fissures  and  later-acquired  defects. 

It  has  already  been  explained  under  harelip  how  fissures  in  the  pos- 
terior margin  of  the  nasal  orifice  may  be  closed  after  mobilization  of 
the  ala  and  freshening  of  the  edges.  A  congenital  median  or  lateral 
fissure  of  the  nose  may  be  similarly  closed.  As  long  as  the  defect  is 
not  too  extensive  or  deep-lj'ing,  or  is  connected  with  other  deficiencies 
of  the  face  or  scalp,  an  incomplete  lateral  fissure  of  the  ala  (Fig.  108, 
Plate  17)  may  be  closed  by  a  simple  technique  similar  to  that  for 
incomj)lete  harelip.     Just  as  in  the  Xelalon  operation   (see  p.  128), 

•Zentral  f.  Chir.,  1910,  No.  48. 


UO  SPECIAL  PLASTIC  PROCEDURES 

an  an<4iilar  incision  is  made  through  the  ala,  parallel  to  the  edge  of 
the  fissure,  and  the  loosened  portion  is  pulled  down  and  the  incision 
sewed  up  in  a  vertical  line. 

In  a  workingman  with  a  congenital  fissure  of  the  right  side  of  the 
nose  (Fig.  108,  Plate  17)  the  operation  was  carried  out  thus: 

A  small  double-edged  knife  was  introduced  in  the  middle  of  the 
fissure  close  to  the  mucous  border  (Fig.  109,  Plate  17)  and  an 
incision  was  made  parallel  to  the  edges  of  the  defect.  At  both  ends 
the  separated  margin  was  left  in  connection  with  the  skin  of  the  nose. 
To  correct  the  deformity  the  loosened  margin  was  drawn  downward 
w^ith  a  strabismus  hook  so  that  the  freshened  surface  took  the  shape  of 
a  rhombus  (Fig.  110.  Plate  17).  and  the  incision  was  sewed  up  in  an 
oblique  line  from  right  to  left  with  four  fine  silk  sutures.  The  result, 
except  for  a  small  protuberance  at  the  upper  edge,  was  a  nasal  orifice 
which  was  normal  in  every  way  (Fig.  Ill,  Plate  17).  If  the  pro- 
tuberance had  not  itself  shrunk  into  shape  within  the  course  of  two 
months  it  would  have  been  removed  by  scissors  or  knife  just  as  the 
nipple  formation  on  the  lip  after  a  harelip  operation.  After  eight 
days  the  stitches  were  removed.  The  patient  remained  in  the  hospital 
longer  on  account  of  other  conditions. 

Acquired  deformities  or  defects  of  the  nose  result  from  injury  or 
follow  operative  procedures  or  destructive  disease.  The  destruction 
may  involve  the  entire  nose;  in  this  case  a  total  rhinoplasty  is  de- 
manded, or  if  jjortions  of  the  nose,  such  as  the  tip,  the  ala  or  the  bony 
bridge,  have  to  be  replaced,  a  partial  rhinoplasty.  The  form  and  the 
extent  of  the  defect  determines  the  choice  of  plastic  procedure,  of 
whicli  tliere  are  many. 

In  order  to  form  a  nose  which  shall  give  lasting  satisfaction  first 
of  all  requires  a  bony  support  and  second  the  formation  of  an  outer 
as  well  as  inner  lining  of  skin,  so  that  it  will  not  shrink.  The  Indian 
method  of  rhinoplasty  from  the  forehead  and  the  Italian  method  from 
the  arm  have  been  abandoned  in  their  original  form  because  the  nose 
made  entirely  of  skin  rapidly  shrinks  together  into  an  ungainly  lump. 
They  are  employed  now  for  repair  only,  if  everything  remains  intact 
except  the  skin  of  the  siu'face. 

These  old  methods  are  useful  for  building  up  a  nose  if  bone  covered 
with  periosteum  is  transplanted  attached  to  the  skin  flap.  After  the 
teaching  of  Kiinig,  a  small  flap  of  skin  is  cut  out  obliquely  on  the 
forehead  and  in  conjunction  with  it  a  flat  shell  of  bone  is  chiseled  out. 


PLASTICS  ON  THE  NOSE  14.1 

The  skin  of  tliis  flap  forms  the  inner  hning  of  the  nose,  and  the  bone 
wliidi  is  attached  to  it  forms  its  framework.  The  outer  covering  must 
be  made  from  anotlier  forehead  tlap  (Konig)  or  from  trianguhir  flaps 
from  the  hiteral  halves  of  the  remnant  of  the  nose  ( Israel) .  In  syphi- 
litic and  traumatic  saddle  nose,  wliicli  results  from  destruction  of  the 
nasal  bones,  these  modifications  of  the  Indian  method  find  application. 

In  the  same  way  the  Italian  method,  if  the  result  is  to  be  lasting 
and  good,  must  be  coml)ined  with  an  osteoplasty.  It  may  be  carried 
out  after  the  method  of  Israel,  the  skin  flap  being  cut  over  the  idna  and 
at  the  same  time  a  piece  of  this  bone  taken  for  the  framework  of  the 
nose,  or  tlie  strip  of  bone  which  shall  serve  as  a  support  after  the  flap 
is  transplanted  must  in  the  first  place  be  transi)lanted  under  the  area 
selected  in  the  skin  of  the  arm  and  allowed  to  heal  in.  The  inner  lining 
of  the  new  nose  must  also  be  taken,  according  to  this  method,  from 
the  skin  of  the  forehead  in  order  that  soft  parts  and  framework  shall 
not  shrivel  up  or  die  after  transjilantation.  The  flap  on  the  arm  before 
union  with  the  root  of  the  nose  is  to  be  lined  with  this  piece  of  skin. 

The  formation  of  an  entire  new  nose  after  these  principles  rarely 
succeeds  in  fulfilling  all  the  cosmetic  requirements.  Improvements 
of  greater  or  less  extent  must  be  carried  out  by  later  operation,  whether 
it  is  the  nasal  orifice,  a  portion  of  the  bridge,  the  ala  or  the  columna 
which  requires  correction.  The  following  observation  will  show  how 
the  various  methods  of  free  and  combined  plastic  procedures  may  be 
employed  for  the  building  up  of  a  nose: 

In  July,  1008,  a  twenty-five-year-old  locksmith  suffered  a  crushing 
injury  of  the  face  in  an  elevator  accident.  The  right  ujiper  jaw  and 
the  root  of  the  nose  were  crushed  and  the  upper  lip  and  the  head 
wounded  in  various  places.  The  middle  portion  of  the  lower  jaw 
was  broken  free,  but  still  remained  attached  to  the  soft  ])arts  of  the 
chin;  it  was  rejjlaced  and  made  fast  by  a  few  deep  catgut  sutures  in 
the  periosteum  and  mucous  membrane.  In  the  nasal  orifice  which 
was  open  the  widest  a  rubber  tube  was  placed  as  far  as  the  naso- 
pharynx and  the  wounds  of  the  soft  parts  were  given  a  dry  sterile 
dressing.  In  August  a  small  s])linter  of  bone  came  down  through  the 
left  side  of  the  nose.  In  ()cto])er  a  sequestrum  al)out  3  cm.  long  and 
14  cm.  wide  came  away  from  the  right  half  of  the  upper  jaw,  in  which 
an  air  cell  could  be  recognized. 

At  the  begimiing  of  .Tamiary,  1009.  all  wounds  were  healed  and 
the  nu'ddle  portion  of  the  lower  jaw  had  grown  in  fast  to  the  lateral 
portions.    The  upper  part  of  the  face  as  a  result  of  the  fractures  of 


142  SPECIAL  PLASTIC  PROCEDURES 

the  jaw  and  of  the  nasal  bones  appeared  flattened  and  badly  disfig- 
m-ed,  so  that  many  attempts  to  And  a  positioii  for  the  injured  man 
failed,  on  account  of  his  objectionable  appearance.  His  union  sent 
him  once  more  to  the  hospital,  in  order  to  correct  the  deformity  as  far 
as  possible. 

Upon  entrance  the  following  observations  were  made  (Fig.  112, 
Plate  18)  :  Both  sides  of  the  upper  jaw  were  markedly  depressed,  so 
that  the  infraoi'bital  margins,  particularly  the  right,  were  considerably 
posterior  to  the  level  of  the  cornea.  This  deformity  was  the  result 
of  fracture  of  the  upper  jaw.  The  cohmina  of  the  nose  was  lack- 
ing, except  for  a  tab  of  skin  a  few  mm.  long.  The  entire  cartilaginous 
nose  Avas  pressed  flat  upon  the  face.  The  bony  framework  Avas  pres- 
ent, but  likewise  sunken,  so  that  the  bridge  appeared  flat  and  wide. 
A  deeply  drawn  fiu'row  between  the  nose  and  the  upper  lip  caused 
the  upper  lip,  which  was  deformed  by  numerous  scars,  to  project 
tumor-like. 

First  the  nose  had  to  be  built  up,  no  external  defects  being  visible 
upon  its  skin  surface.  For  this  purpose  the  upper  lip  was  separated 
from  the  nose  in  the  transverse  furrow,  and  the  nose  was  mobilized 
through  loosening  the  upper  edge  from  the  bone  (Fig.  113,  Plate  18) . 
Thereupon  a  small  transverse  incision  Avas  made  through  the  skin  at 
the  root  of  the  nose  (Fig.  114,  Plate  18)  and  the  skin  A\^as  lifted  from 
the  bony  and  cartilage  framcAvork  doAAii  to  the  tip  by  means  of  a 
pointed  elcA^ator,  so  that  a  subcutaneous  canal  about  1  cm.  Avide  and 
5  cm.  long  Avas  formed.  In  this  process  the  nasal  mucous  membrane 
Avas  not  injured. 

The  attempt  to  straighten  up  the  nose  Avith  the  elevator  by  means 
of  this  subcutaneous  canal  and  its  mobilization  Avas  impossible  on 
account  of  scar  contraction  Avithin  the  nose.  Accordingly,  the  bony 
framcAvork  inside  had  to  be  divided  Avith  a  chisel.  Since  the  small 
remnant  of  tlie  columna  increased  tlie  strong  tension,  it  Avas  cut 
through.  After  the  mobilization  of  the  framcAvork  of  the  nose  was 
successfully  accomplished,  the  nose  was  straightened  up  Avith  the  index 
finger  and  by  means  of  lateral  pressure  Avith  the  other  hand  the  nasal 
bones  Avere  shoved  together.  In  this  position  the  nose  Avas  held  by 
means  of  a  rubber  tube  the  size  of  a  finger  Avound  Avith  A'ioform 
gauze  (Fig.  114,  Plate  18).  The  transverse  separation  of  the  upper 
lip  for  the  time  being  was  disregarded. 

In  order  to  keep  the  nose  permanently  in  this  corrected  position  it 
was  given  a  ncAV  support  by  means  of  a  free  transj^lantation  of  bone 


Krause-Heymann-Ehrcnfried.  Jab.  18. 

Rhinoplasty:  restoration  of  the  ridge  of  the  nose  by  means 
of  a  tibial   transplant  (Lexer). 


Elevator 


Transverse  incision 
at  root  of  nose 


Transverse  incision 

between  nose  and 

upper  Up 


Chisel 


Fig. !  12.  Deformity  9  montiis  after  injury. 


Fig.  113.  Mobilization  of  the  soft  parts. 


Drainage  tube 


Fig.  114.  Rubber  tube  wrapped  in  gauze  serving 
as  provisional  support  of  nose. 

Tibial  transplant 


Tibial  transplant  I   i 

Fig.  115.  Removal  of  strip  from  crest  of  tibia. 


Retractor 


Fig.  116.  Transplantation  of  section  of  tibi; 


Elevator 


Fig.  117.    Burying   upper  end   of  transplant    untlcr 

_  ^        „■  skin  nf  forehead. 

Kebman  Company,  N'cw  Nork 


Fig.  118.    Cosmetic    result    after 
healing   in    of  tibial   transplant. 


Krause-Heymann-Ehrenfried. 


Tab.  19. 


Plastic  restoration  of  sunken   cheek  bv  free  transplantation  of  fat. 


/ 

Old  scar 

Fig.  IIQ.  Risjht  cheek  is  sunl<en  in. 


'&■  ^ '  ^-  '^'to"' 


Poch't  in  cheek 

Fig.  120.  Packing  pocket  witii  gauze 


Fi".  121.  Removal  of  fat-fascia  flap  from  gluteal  region. 


Fig.  122.  Implanting  fat  flap  into  pocket  in  cheek. 


Rcbinan  Company,  New  York. 


RESTORATION  OF  THE  NOSE  U3 

after  the  method  of  Lexer.  The  strip  0  cm.  loncf  necessary  for  this 
purpose  was  taken  together  witli  its  periosteum  from  the  anterior 
edge  of  the  tibia  (Fig.  115,  Plate  18).  Through  a  longitudinal  in- 
cision just  over  the  shin,  skin  and  fascia  were  divided  and  periosteum 
exposed.  Then  small  transverse  furrows  were  cliiseled  in  the  bone 
at  the  uj)i)er  and  lower  ends  of  the  incision  and  the  piece  of  bone  of 
measured  length  with  its  periosteum  was  chiseled  out.  The  thickness 
of  the  bone  was  about  3  mm. 

This  piece  from  the  tibia,  with  this  chiseled  surface  toward  the  nasal 
ca\ity  and  the  periosteal  surface  toward  the  skin,  was  shoved  down 
into  the  skin  pocket  from  the  glabella  to  the  tip  of  the  nose,  using  a 
single  hook  for  lifting  up  the  skin  (Fig.  116,  Plate  18) .  About  1  cm. 
of  the  end,  which  projected  from  the  wound,  was  placed  in  a  second 
shallow  pocket,  which  was  formed  with  the  raspatory  through  the 
transvei'se  incision  in  the  neighborhood  of  the  root  of  the  nose  (Fig. 
117,  Plate  18).  Finally  the  small  transverse  wound  on  the  glabella 
was  closed  with  two  sutures  and  the  skin  wound  over  the  tibia  with 
seven  sutures.  The  result  of  the  bony  transplantation  was  awaited 
a  few  weeks. 

When  healing  was  assured  (Fig.  118,  Plate  18),  the  formation  of 
a  columna  and  padding  of  the  sunken  cheeks  was  undertaken.  As  a 
result  of  the  depressed  fracture  of  both  sides  of  the  superior  maxilla 
the  entire  right  jjortion  of  the  cheek  except  the  nose  was  sunken  con- 
siderably below  the  level  of  the  face  (Fig.  119,  Plate  19).  Since  a 
correction  of  the  depressed  fracture  of  the  splintered  superior  maxilla 
did  not  seem  feasible,  the  deformity  was  corrected  by  means  of  a  sub- 
cutaneous padding  with  a  free  flap  composed  of  fat  and  fascia.  In 
a  thin  man  ])l('nty  of  fat  may  be  derived  from  the  gluteal  region.  To 
make  the  ])ocket  in  which  the  flap  was  to  heal,  the  entire  superior 
maxilla  up  to  the  infra-orbital  edge  was  freed  as  far  as  possible  by 
bhmt  dissection,  with  the  help  of  a  few  snips  of  the  scissors.  Ey 
packing  this  pocket  with  gauze  (Fig.  120.  Plate  19)  and  by  com- 
pression from  outside  during  the  remainder  of  the  operation,  the 
bleeding  could  readily  be  controlled. 

Meanwhile  the  fat-fascia  flap  was  removed  from  the  gluteal  region 
(Fig.  121.  Plate  19).  The  skin  was  dissected  up  through  a  linear 
incision  and  a  piece  of  tissue  two  inches  long  l)y  one  inch  wide,  con- 
sisting of  gluteal  fat  and  su])erficial  fascia,  was  taken  out.  This 
piece  in  its  entirety,  without  allowing  fingers  to  come  in  contact  with 
it,  was  placed  in  the  prepared  pocket  in  the  cheek  (Fig.  122,  Plate  19) . 


144  SPECIAL  PLASTIC  PROCEDURES 

The  fascia  lay  upon  bone  and  the  fatty  layer  next  the  skin.  After  the 
skin  was  closed  over  it  with  five  sutures,  it  transpired  that  the  trans- 
planted fat  was  somewhat  too  thick,  particularly  over  the  zygoma, 
so  that  the  skin  bulged  slightly. 

Then  the  formation  of  the  columna  of  the  nose  was  undertaken. 
The  small  remnant  of  the  original  columna  wliich  remained  at  the  tip 
of  the  nose  was  employed  (Fig.  123,  Plate  20).  After  freshening 
this  piece,  it  was  hardly  more  than  one-half  cm.  long.  The  remaining 
portion  had  to  be  made  from  the  two  wings  of  the  nose  and  the  pos- 
terior wall  of  the  nasal  orifice.  The  upper  lip  could  not  be  employed 
for  this  purpose  because  it  had  been  changed  almost  completely  into 
scar  tissue.  The  transverse  scar  which  ran  across  the  base  of  the 
upper  lip  was  of  particular  disadvantage,  because  it  pulled  the  lip 
in  strongly  and  held  it  fast  to  the  bone. 

This  scar  was  divided  transversely  (Fig.  124,  Plate  20).  and  then 
from  the  left  ala  and  the  posterior  border  of  the  nasal  orifice  a  flap 
lYo  cm.  by  Y2  ^n^'  "^^'^s  taken  (Fig.  12.5,  Plate  20) .  The  nasal  mucous 
membrane  and  the  periosteum  of  the  lower  portion  of  the  vomer  Avere 
cut  at  the  same  time  in  connection  with  this  flap,  lifted  from  the 
underlying  stratum  with  forceps  and  placed  upright  (Fig.  126, 
Plate  20).  In  this  way  the  missing  portion  of  the  columna  could  be 
replaced  and  united  with  the  remnant  remaining. 

In  order  to  give  the  septum  support  from  the  right,  the  right  ala, 
which  had  been  depressed  by  strong  scar  contraction  and  had  been 
displaced  outwards,  was  loosened  with  a  knife  from  its  substratum 
(Fig.  127,  Plate  20).  Then  it  was  turned  in  medially  and  fastened, 
in  its  original  position  as  the  posterior  boundary  of  the  right  nasal 
orifice,  to  the  newly  formed  columna,  by  means  of  two  sutures  (Fig. 
128,  Plate  20) .  In  order  to  prevent  the  lip  from  being  drawn  in  again 
by  scar  contraction,  the  lip  and  the  posterior  wall  of  the  nose  in  their 
entire  thickness  were  mobilized  upon  the  substratum  and  were  then 
united  after  bevelling  the  edges  with  a  knife. 

The  patient,  except  for  short  interruptions,  had  passed  an  entire 
year  in  the  hospital.  On  discharge  his  appearance  was  much  more 
attractive.  The  cheeks  retained  a  portion  of  their  new  roundness, 
and  no  longer  showed  the  excess  which  appeared  immediately  after 
the  operation.  The  columna  of  the  nose  was  replaced  and  the  ridge 
of  the  nose  stood  out  from  the  face  after  the  complete  healing  in  of  the 
piece  of  tibia. 


Krause-Heymann-Ehren  fried. 


Tab.  20. 


Formation   of  a  column  a  of  the  nose. 


Remains  of  columna 


h"ig.  123.  Freeing  up  remnants  of  columna. 


Incision  for  mobili- 
zation of  upper  lip 


Freed  up  remains 

of  columna 


Flap  from 
posterior  portion 
of  nasal  orifice 


Fig.  124.   Incision  for  formation  of  columna. 


Upper  lip  drawn 
in  bv  scar  contraction 


Newly  formed 
columna 


Fig.  125.  Formation  of  new 

columna,  from  posterior  margin 

of  nasal  orifice. 


Right 

ala    ■ 


Fig.  126.   The  new  columna  is  united  to  the 
remnants  of  the  old. 


Fig.  127.  Freeing  up  the  right  ala. 


Upper  lip 


Fig.  128.  Right  nasal  orifice  completed 
by  suture  of  riglit  ala  to  median  line. 


Rclmiaii  Coinp.nny,  New  York. 


RESTORATION  OF  THE  NOSE  145 

>\s  this  observation  shows,  after  injuries  of  the  face,  phistics  of  the 
nose  and  cheeks  not  infrequently  have  to  be  carried  out  together. 
Accordingly  in  the  following  section  another  case  of  this  sort  will  be 
cited. 

Fritz  Konig  has  replaced  defects  which  involve  only  the  ala  of  the 
nose  and  cause  very  disagreeable  results  by  using  free  grafts  taken 
from  the  shell  of  the  ear.  He  cuts  a  wedge  comprising  all  the  layers 
out  of  the  helix  and  plants  it  in  the  freshened  defect  of  the  ala.  In 
this  transphuitation  the  flap  is  so  placed  that  the  edge  of  the  helix 
forms  the  latei'al  border  of  the  nasal  orifice,  and  the  surface, 
which  was  originally  directed  backward  against  the  cranium,  after 
transplantation  forms  the  outer  surface  of  the  ala.  These  free  trans- 
plantations of  the  shell  heal  in  well,  but  their  nutrition  should  not  be 
disturl)ed  by  stitches  placed  too  closely  together  along  the  edge,  or 
tied  too  tight;  this  particularly  has  to  do  with  the  cartilaginous  layer. 

PLASTIC  OPERATIONS  ON  THE   CHEEK 

Plastic  restoration  of  the  cheek  is  indicated  in  defects  which  result 
from  injuries,  noma,  or  after  the  extirpation  of  malignant  tumors. 
Scar  lockjaw,  of  which  the  cause,  omitting  disease  of  the  articulation 
of  the  lower  jaw,  may  lie  in  changes  in  the  soft  parts  of  the  cheek, 
under  certain  circumstances  demands  removal  and  replacement  of  the 
affected  tissue. 

In  plastics  on  the  cheek,  as  in  rhinoplasty,  care  should  be  taken 
that  the  mucous  membrane  as  well  as  the  outer  skin  be  replaced  by 
tissue  which  will  not  shrink.  The  laying  of  a  pediculated  flap  over  the 
defect  will  cover  it  externally,  but  it  will  leave  a  fresh  wound  in  place 
of  the  mucous  membrane  of  the  mouth  which,  if  it  is  allowed  to  go 
uncovered,  must  7-esult  in  scar  contraction  of  the  transplanted  flap 
and  contraction  of  the  articulation  of  the  jaw.  In  order  to  prevent 
this  the  oral  surface  of  the  flap  must  be  covered  with  mucous  mem- 
brane or  skill.  Mucous  membrane  flaps  may  be  taken  from  the  neigh- 
borhood and  laid  over  the  wound,  which  is  accomplished  with  fair 
readiness  on  account  of  the  elasticity  and  movability  of  the  oral 
mucous  membrane.  For  covering  with  skin  Thiersch  grafts  may  be 
used,  or  the  wound  surface  may  be  lined  with  a  second  ])ediculated 
or  free  flap.  If  a  skin  flap  from  the  neighborhood  is  employed  for 
this  purpose,  a  place  which  is  without  hairy  growth  is  to  be  chosen, 
so  that  later  hair  will  not  grow  within  the  mouth. 

In  a  case  of  carcinoma  which  destroyed  the  entire  cheek,  following 


146  SPECIAL  PLASTIC  PROCEDURES 

the  proposal  of  Israels,  we  proceeded  in  svich  fashion  that  the  defect  the 
size  of  the  palm  of  the  hand  which  resulted  from  the  extirpation  was 
covered  in  hy  a  flap  taken  from  one  side  of  the  neck  (Fig.  129, 
Plate  21).  The  wide  and  long  pedicle  was  divided  ten  days  later, 
trimmed  properly,  and  immediately  sewed  into  the  upper  edge  of  the 
defect,  so  that  it  filled  the  defect  as  a  doubled  skin  flap  (Fig.  130, 
Plate  21 ) .  Fourteen  days  later  the  doubled  edge  was  cut  through  and 
the  two  fresh  wound  edges  were  united,  the  inner  to  mucous  mem- 
brane and  the  outer  to  skin.  Both  portions  of  this  flaji  healed  in,  with 
the  formation  of  a  fistula  in  the  cheek.  A  few  weeks  later,  before  the 
fistula  could  be  closed,  the  patient  died  of  aspiration  pneumonia  and 
internal  metastasis. 

Bardenheuer  formed  a  similar  flap  for  the  restoration  of  a  defect 
of  the  cheek  from  the  forehead.  The  pedicle  was  situated  at  the 
zygoma. 

In  extensile  malignant  growths  the  destructive  effect  and  the  loss 
of  tissue  which  residts  from  operative  removal  is  not  restricted  to  the 
middle  of  the  cheek,  but  is  likely  to  include  also  the  corner  of  the  mouth, 
a  portion  of  the  nose  or  the  border  of  the  orbit.  Accordingly,  these, 
as  well  as  the  cheek,  must  be  replaced  according  to  the  principles 
already  expounded.  The  following  example  will  demonstrate  what 
may  be  done  in  a  severe  case: 

In  a  fifty-year-old  patient,  six  months  before  admission,  the  left 
half  of  the  nose  was  removed  elsewhere  for  carcinoma.  In  addition 
to  the  ala  of  the  nose,  the  nasal  cartilage  on  the  left  side  was  also 
lacking;  on  the  other  hand,  the  cartilage  and  skin  forming  the  ridge 
and  the  tip  of  the  nose  were  present  (Fig.  131,  Plate  22) .  An  attempt 
made  by  others  to  implant  a  piece  of  cartilage  from  a  rib  under  the 
mucous  membrane  of  the  left  cheek  miscarried,  for  a  fistula  in  the  skin 
of  the  cheek  exuded  pus  on  pressure.  ^Moreover,  the  left  inner 
canthus  was  eaten  by  a  deep  funnel-like  ulcer  with  hard  edges,  which 
was  diagnosed  as  recin'rent  carcinoma.  Since  there  was  marked  injec- 
tion of  the  vessels  of  the  conjunctiva  of  the  liulh  in  the  neighborhood 
of  the  ulcer,  with  a  certain  amount  of  infiltration,  it  was  decided  that 
radical  extirpation  with  sacrifice  of  the  eye  was  indicated. 

The  operation  began  with  exenteration  of  the  orbit  (see  p.  156). 
The  outer  canthus  was  split  down  to  bone  and  the  entire  content  of 
the  orbit  was  cleaned  out  with  a  raspatory.  Both  eyelids  were  spht 
vertically  and  the  medial  halves  were  removed.  In  order  to  excise  all 
the  involved  tissue,  the  skin  incision  was  carried  down  to  bone  medially 


Krause-Heymann-Ehrenfried. 


Tab.  21. 


Plastic  repair  o{  cheek  after  James  Israel. 

T/if  skin  flap  is  implantfil  into  defect  in  cheek 


Fig.  12Q.  Flap  c.nrried  to  cheek  from  neck. 

Rpidennal  surface,  after  foldina  flap  on  itself 


Fold 


Fig.  130.  Folding  (lie  flap  over  after  dividing  the  pedicle. 


Rcbman  Company,  New  York. 


Krause-Heyniann-F-hrenfried. 


Tab.  22. 


Plastic  repair  of  large  defect  of  face.  T. 

Defect  at  inner  canthtis 


Defect  of  a  la 


Fig.  131.  Defect  after  extirpation  of  a  carcinoma. 


Skill  of  clieelt 

turned  baeli      Fresliened  edge 
of  old  defect 


Frontal  sinus 


Orbit 


Half 

of  upper 

lid 


Antrum  of 
High  more 


Fig.  132.  Partial  resection  of  upper  jaw. 


Split 

upper 

lip 


Antrum  of  tine  of  incision  of  mucous 
Right  half  of  iiiiper  Up       Highmoie      membrane  of  vomer 


Fig.  133.  Chiseling  away  of  hard  palate. 


Left  half  o] 
upper  lip 


Infraorbital  nerve         Frontal  sinus 


Fig.  134.  Appearance  of  wound  cavity. 

Ribman  Company,  New  York. 


Posterior  wall  of 
left  nasal  cavity 


Suture  of  mucous  membrane 
and  cheek 


Fig.  135.  Lining  nasal  cavity  with  a  mucous 
membrane  flap  from  vomer. 


PLASTICS  ON  THE  CHEEK  147 

to  the  bridge  of  the  nose  in  such  a  way  as  to  suitouikI  tlie  recurrent 
ulcer  at  the  inner  canthus.  Its  removal  followed  in  connection  with 
the  nasal  bone  and  the  nasal  process  of  the  frontal  bone  (Fig.  132, 
Plate  22).  In  chiseling  off  these  portions  of  bone  the  frontal  sinus 
was  exposed.  The  left  nasal  cavity  having  first  been  packed  with 
sterile  gauze,  no  blood  could  flow  into  the  mouth. 

The  cilia  and  the  mucous  membrane  of  the  remaining  portions  of 
the  eyelids  were  excised  and  the  two  freshened  edges  were  sewed  to- 
gether. Xext  the  defect  of  the  ala  of  the  nose  in  which  no  carcinoma 
Avas  visible  was  freshened  up  by  continuing  the  incision,  which  ran 
over  the  bridge  of  the  nose.  In  loosening  up  the  old  oj^erative  scar 
there  appeared  under  the  skin  down  to  the  palatal  process  and  as  far 
as  the  alveolar  process  hard  and  suspicious-looking  places.  After 
cutting  the  septum  of  the  nose  along  its  base  and  after  laying  back 
the  upper  lip  split  along  the  median  fiu'row,  a  considerable  surface 
of  the  upper  jaw  involved  by  carcinoma  was  exposed  (Fig.  132, 
Plate  22).  This  in  conjunction  with  the  left  half  of  the  hard  palate 
was  separated  from  the  alveolar  process  by  two  strokes  of  the  chisel, 
opening  wide  the  antrum  of  Highmore  (Fig.  133,  Plate  22).  In 
oi-der  to  be  sure  that  all  the  malignant  disease  was  removed,  the  nuicous 
membrane  of  the  antrum  and  the  infraorbital  nerve  which  hung  free 
were  removed  at  the  same  time  (Fig.  ItH.  Plate  22).  All  cavities 
opened  by  chiseling  were  packed  with  iodoform  gauze,  and  the  split 
upper  lip  was  reunited  by  suture  of  the  mucous  and  skin  surfaces  as 
far  as  the  border  of  the  nasal  orifice. 

To  replace  the  outer  border  of  the  nasal  oi-ifice  and  the  destroyed 
ala,  it  was  planned  to  use  the  mucous  membrane  of  the  left  surface 
of  the  vomer  as  a  lining  flap,  and  skin  cut  from  the  cheek  as  an  outer 
covering. 

For  this  purpose  the  mucous  membrane  on  the  vomer  was  incised 
as  far  up  and  back  as  possible  (Fig.  134,  Plate  22"),  and  loosened  with 
a  raspatory  from  the  columna  to  the  bridge  of  the  nose,  where  a 
pedicle  Avas  left.  The  under  surface  of  the  posterior  edge  of  this  wide 
pediculated  flap  of  mucous  membrane  was  sewed  against  the  skin  of 
the  left  cheek,  which  had  been  drawn  over  to  meet  it,  and  the  lower 
edge  to  the  remnant  of  the  medial  border  of  the  nasal  orifice  (Fig.  13.5, 
Plate  22).  In  so  far  as  it  lay  over  the  antrum  of  Ilighiiiore  and 
over  the  defect  in  the  palate,  it  closed  ott'  the  nasal  cavity  satisfactorily 
from  the  mouth.  At  the  same  time  it  formed  a  posterior  wall  for  the 
nasal  orifice.    The  end  of  the  iodoform  drain  in  the  orbit  and  against 


148  SPECIAL  PLASTIC  PROCEDURES 

the  base  of  the  skull  was  brought  down  over  this  mucous  membrane 
and  out  through  the  new  orifice,  and  the  defect  aliove  the  orbit  was 
lessened  by  several  stitches.    The  operation  was  thereupon  interrupted. 

Ten  days  later  it  appeared  that  the  flap  of  mucous  membrane 
which  had  been  loosened  from  the  vomer  had  not  healed  in  on  account 
of  tension,  and  the  soft  parts  of  the  left  cheek  had  pulled  so  strongly 
on  the  stitches  that  they  had  pulled  out  and  the  flap  had  retracted. 
At  the  scarred  edge  of  the  upper  lip  appeared  a  few  small  infiltrated 
nodes,  which  were  apparently  carcinomatous,  and  for  that  reason  ex- 
cision of  the  upper  two-thirds  of  the  upper  lip  together  with  the 
mucous  membrane  was  demanded  (Fig.  136,  Plate  23). 

In  order  to  carry  out  a  plastic  restoration  of  the  left  ala  of  the 
nose  and  of  the  cheek,  care  was  taken  first  to  make  a  lining  flap,  since 
the  flap  from  the  forehead  which  was  originally  employed  to  coA'er 
in  the  large  defect  had  in  the  course  of  time  rolled  itself  up  into  an 
unformed  mass.  To  be  sure,  one  had  to  be  sparing  with  the  com- 
paratively slight  material  at  hand.  Accordingly  a  flap  of  skin  20  mm. 
by  55  mm.  was  cut  close  above  the  left  eyebrow  (Fig.  137,  Plate  23). 
The  pedicle  lay  to  the  right  over  the  glabella,  but  it  did  not  go  beyond 
the  middle  line.  In  order  to  assure  a  permanent  suture  of  this  flap 
in  its  appointed  place,  the  scarred  edge  of  skin  of  the  ridge  of  the  nose 
was  freshened  and  undermined  for  a  few  mm.  The  pediculated  flap 
was  then  turned  about  at  right  angles,  with  epidermal  side  in,  and  it 
was  sewed  with  catgut  into  the  groove  under  the  freed  edge  of  the 
skin  of  the  ridge  of  the  nose  (Fig.  138,  Plate  23't.  Then  for  lining 
the  defect  laterally  a  strip  of  skin  several  mm.  wide  was  turned  down 
from  the  edge  of  the  defect  of  the  cheek. 

Before  the  cheek-nose  flap  was  planted  upon  this  completed  lining 
flap  the  defect  in  the  left  upper  lip  had  to  be  restored  by  a  rectangular 
flap  taken  from  the  left  cheek  with  a  pedicle  running  dowuAvard  and 
outward  (Fig.  139.  Plate  23).  in  such  a  way  that  later  the  hairs  of 
the  beard  in  their  growth  would  follow  the  direction  of  the  hairs  of  the 
mustache.  The  lower  edge  of  the  plastic  flap  coincided  in  part  -VAath 
the  horizontal  edge  of  the  wound  of  the  upper  lip. 

After  exact  suture  of  this  cheek  flap  into  place  to  form  a  new 
upper  lip  (Fig.  140,  Plate  23)  a  large  defect  still  remained  behind, 
which  included  the  medial  half  of  the  lids,  half  of  the  cheek  and  the 
left  ala  of  the  nose. 

To  cover  in  this  hole  a  pro])ortionately  larger  flap  of  skin  was 
taken  from  the  left  half  of  the  forehead  and  beyond  the  middle  line. 


Krause-Hcymanii-Ehrcnfricil. 


Tab.  23. 


P^l.istic   repair  of  large  defect  of  face.   11. 


Shrunken  tnncoits  membrane  flap 

I 


Flap  from  forehead 


Recurrence 


Fig.  136.  Wound  cavity  after  shrinking;  back  of  ciieek  flap; 
excision  of  recinTcncc  on  upper  lip. 


;"i.s{.  137.  Formation  of  a  flap  on  the  forehead, 
for  linins^  nasal  passage. 


Lining  flap 
front  forehead 


Cheek  flap 
for  lininji 


Flap  for 

restoration  of 

upper  lip 


Fig.  138.  Suture  of  lining  flap;  formation 
of  new  lining  flap. 


Fig.  139.  Formation  of  upper  lip. 


m^A 


Direction  of  hairs 
of  the  heard 


Fig.  140.  Suture  of  flap  from  cheek 
replacing  defect  of  lip. 


RcbiiLin  Company,  New  York. 


Krause-Heyniann-F^hrenfrictr 


Tab.  24. 


Pla.stic  repair  of  large  defect  of  face.  III. 


Gauze 


Fig.  141.  Gauze  used  as  pattern  for 
size  and  shape  of  flap. 


Gauze  pattern 


W'ontnl  ec/o. 


Forehead 
flap  turned 

down  to 
cover  defect 


Fig.  142.  Outlining  the  flap  upon  tlie 
forehead,  from  pattern. 


Fig.  143.  Undermining  skin  of  forehead. 


Mattress 

suture,  to  hold 

olded  edge 


Fig.  144.  Formation  of  anterior 
margin  of  left  nasal  orifice. 


Rebman  Company,  New  York. 


PLASTICS  OX  THE  CHEEK  149 

The  lower  ed^e  of  tliis  flap  corresponded  to  the  upper  edge  of  the 
defect  which  resulted  from  the  cutting  of  the  flap  to  line  the  ridge 
of  the  nose  (Fig.  138,  Plate  23).  The  pedicle  of  the  flap  (Fig.  142, 
Plate  24)  lay  in  the  neighborhood  of  the  right  inner  canthus.  The 
forehead  flap  was  patterned  after  a  piece  of  gauze  (Fig.  141, 
Plate  24)  which  was  cut  to  fit  the  defect.  Considerable  allowance 
of  skin  had  to  be  made  for  the  corner  out  of  which  later  the  edjje 
of  the  new  nasal  orifice  was  to  be  created.  The  flap  consisted  only 
of  skin  and  superficial  fascia.  The  periosteum,  as  is  always  the  case 
when  bone  is  not  to  be  included,  remained  undisturbed  upon  the 
frontal  bone,  because  otherwise  necrosis  of  the  superficial  layer  of  the 
bone  might  result  through  drying,  in  case  the  uncovered  portion  was 
not  immediately  covered  by  suture  or  transplantation. 

The  defect  which  remained  in  the  forehead  after  lifting  the  flap 
could,  except  for  a  small  remnant,  be  closed  after  extensive  under- 
mining of  the  sm-rounding  skin  (Fig.  143,  Plate  24)  and  by  the  aid 
of  tension  sutures. 

The  border  of  the  left  nasal  orifice  had  to  be  made  on  the  flap 
which  was  to  be  turned  down  from  the  forehead,  before  sewing  it  in 
place.  For  this  purpose  at  the  proper  place  in  the  skin  as  much  as 
possible  of  the  subcutaneous  tissue  was  trimmed  away,  and  the  thinned 
edge  was  doubled  over  and  held  bj'  a  mattress  suture  so  as  to  form 
a  rounded  margin  of  skin  (Fig.  144,  Plate  24).  The  upper  edge  of 
the  turiK'd-up  margin,  now  lying  in  the  nasal  cavity,  was  made  fast 
within  by  means  of  three  interrupted  catgut  sutures.  After  the  for- 
mation of  the  margin  of  the  nasal  orifice,  the  flap  was  united  with 
precision  to  the  skin  of  the  ridge  of  the  nose,  the  edge  of  which  had 
previously  been  undermined. 

Xow  the  flap,  attached  to  the  ridge  of  the  nose,  was  brought  down 
over  the  i-ight  side  of  the  face  as  a  cover  for  the  two  lining  flai)s,  one 
for  the  cheek  (Fig.  14.5,  Plate  2.5)  and  the  other  for  the  ala  of  the 
nose  (Fig.  147,  Plate  25),  and  was  united  with  them  on  its  inner 
surface  by  several  catgut  sutures.  The  margin  of  the  i\asal  orifice 
made  from  the  doubled-over  flap  was  united  below  medially  with  the 
skin  edge  at  the  top  of  the  nose,  and  in  order  to  form  a  naso-lal)ial 
fold  (Fig.  146,  Plate  25)  a  small  oblique  incision  was  made  through 
the  doubled-up  edge  of  the  flap  at  the  point  of  junction  with  the  pos- 
terior edge  of  the  orifice.  Laterally  the  edge  of  the  flaj)  from  the  fore- 
head was  united  with  the  cheek,  first  the  flap  which  had  been  previously 
loosened  up  to  be  used  as  lining  for  the  cheek  being  sutured  with 


150  SPECIAL  PLASTIC  PROCEDURES 

catgut  to  its  inner  surface  (Fif?.  147,  Plate  25).  In  tyintr  tliese  four 
buried  sutures  there  resulted  a  hollowing  in  which  resembled  the  nor- 
mal furrow  between  the  nose  and  the  cheek  (Fig.  148,  Plate  25). 
Then  the  skin  edges  were  united  to  each  other.  Finally,  over  the  orbit 
the  outer  edge  of  the  flap  had  to  be  united  with  the  remains  of  the  two 
eyehds  (Fig.  148,  Plate  25). 

Below  and  to  the  outer  side  there  remained  a  rhomboid  defect  in 
the  cheek  where  the  flap  had  been  taken  for  plastic  restoration  of  the 
lip.  This  defect  could  be  closed,  except  for  a  small  remnant,  by  three 
interrupted  silk  sutures,  which  were  introduced  from  the  lateral  corner 
forward.  The  sutures  created  no  tension  on  the  flaps  which  had  been 
employed  for  the  plastic  on  the  lip  or  on  the  nose.  Two  weeks  later 
the  pedicle  of  the  flap  from  the  forehead  was  divided  and  turned  up. 
It  was  used  to  close  the  uncovering  area  in  the  forehead. 

During  the  next  four  weeks  the  flaps  healed  solidly  in  place,  except 
for  the  line  of  suture  between  the  upper  lip  and  the  new  ala  of  the 
nose,  which  pulled  out,  so  that  the  deficiencies  at  the  lateral  margin 
of  the  nasal  orifice  over  the  upper  lip  made  further  operation 
necessary. 

In  order  to  form  the  lateral  margin  of  the  nasal  orifice,  which  was 
still  lacking  (Fig.  149,  Plate  26),  the  upper  edge  of  the  lip  was  freed 
with  a  two-edged  knife,  turned  upwards,  and  sewed  to  the  tip  of  the 
nose  (Fig.  150,  Plate  26).  By  close  examination  of  the  edge  of  the 
defect  of  the  cheek,  which  had  rolled  inward  through  scar  contraction 
(Fig.  151,  Plate  26),  it  was  apparent  that  a  portion  of  the  lining  had 
loosened  and  retracted.  Accordingly  for  a  new  lining  the  marginal 
portion  which  had  rolled  inward  was  so  separated  that  a  sin-face  from 
a  few  mm.  to  1  cm.  wide  could  be  employed.  For  this  purpose  it  was 
turned  inward  and  loosely  held  by  a  few  interrupted  sutures.  As  a 
result  naturally  the  defect  of  the  cheek  was  considerably  increased 
in  size  and  to  cover  it  in  a  new  flap  had  to  be  cut  from  the  neck. 

This  flap  (Fig.  152,  Plate  26)  had  a  pedicle  to  the  outer  side  of 
the  corner  of  the  mouth.  It  was  loosened  from  the  chin  and  the 
fascia  of  the  neck  and  Avas  sewed  with  a  few  catgut  sutures  to  the 
portion  of  the  skin  which  had  been  cut  for  lining,  and  to  the  edges 
of  the  defect  with  silk  (Fig.  153,  Plate  26).  The  secondary  defect 
on  the  neck  was  as  far  as  possible  imited  in  a  transverse  line  without 
distortion  (Fig.  154,  Plate  26).  In  a  short  time,  after  the  skin  flap 
had  healed  in,  the  patient  returned  home. 


Krause-Heyni.inii-Fihrcnfried. 


Tab.  25. 


Plastic  repair  of  lari^c  defect  of  face.   1\\ 


Sutures  not  tied 

Fig.  145.  Union  of  external  and  linin*^  flaps. 


1- 

incision 

Fig.  146.  Formation  of  naso  labial  fold. 


Li/ii/isr  the  lateral  margin 

Fig.  147.  Closure  of  defect  completed. 


Tension  suture 


Uncovered  < 


Union  of  flop  and 
remnant  of  eyelid 


Nasolabiul  fold 


Defect  of  check 


man  Company,  New  York. 


Fig.  148.  Appearance  after  completion  of  suture. 


Krause-Heymann-Ehrenfrieii. 


Tab,  26. 


Plastic   rc])air  of  lari^'c   defect  (if  face.  Y. 


Rg.  150.  Formation  of  lateral 
martjin  of  nasal  orifice. 


Fl<ifi  for  lining 


Fig.  149.  Defect  between  tip  of  nose, 
cheek  and  upper  lip. 


Fig.  151.   A  portion  of  tlie  cheek 

flap  which   has  rolled   in   is  split 

off  for  lining. 


mf 


Fig.  152.  Defect,  and  flap  to  cover  it 
outlined  on  neck. 


Fig.  153.  Suture  of  flap  to  edge 
of  defect 

^      Deffct  reiiKihiing  abovv 


Defect  below 


Fig.  154.  Appearance  after  completion  of  suture. 


^ebinaii  Company,  New  Vorli. 


BLEPHAROPI-ASTY 


151 


BLEl'HAROPLASTY 

Plastic  operations  are  necessary  in  defects  or  anomalies  of  position 
of  the  upper  and  lower  lids.  Defects  of  the  eyelids  result  either  from 
injuries  or  they  are  the  result  of  mali^nuuit  or  other  destructive  dis- 
ease. In  the  discussion  of  plastic  flaps  after  the  Indian  method  a  case 
is  descrihed  in  which  the  replacement  of  the  medial  half  of  the  upper 
lid  after  the  extirpation  of  a  carcinoma  is  demonstrated   (see  p.  102). 

In  similar  diseases  of  the  lower  lid  the  technicpie  of  Langenheck 
may  be  made  use  of,  in  which  the  skin  for  the  newly  formed  lid  is  cut 
out  of  the  cheek   (Fig.  158)   and  the  secondary  defect  is  closed  im- 


(rl 


"^ 


M'      / 


Fic.  158 


Fig.  1.-.9 


mediately  after  undermining  its  edges,  or  is  covered  with  Thiersch 
grafts.  The  following  schematic  drawings  will  explain  the  procedure 
in  such  cases.  For  three-cornered  defects  Czerinak*  recommends 
the  Szymanowski  modification  of  Dieffenbach's  technique.  This  con- 
sists in  outlining  the  outer  angle  of  the  flap  as  acute  as  possible 
(Fig.  1.59),  in  order  that  this  angle  of  the  secondary  defect  will 
allow  of  easy  closure,  and  the  lower  lid  will  have  a  high  support. 

The  free  transj)lantation  of  portions  of  skin  may  also  be  used  to 
good  purpose  in  defects  of  the  eyelids.  Whole-thickness  flaps  heal 
particularly  well  on  the  cheek  and  lower  lid.  as  Wolfe  had  shown 
before  Krause  took  up  the  subject.  On  the  upper  hd  free  transplan- 
tation of  skin  is  ])articularly  valuable,  becaiise  the  defects  which  extend 
over  the  eyebrow  can  be  covered  by  flaps  which  are  taken  from  the 

•Die  augenur/.tliilu'ii  Operatioiicn;  licrliii  and  Vienna,  I'JOS,  \'>j1.  2. 


152  SPECIAL  PLASTIC"  PROCEDURES 

border  of  the  scalp,  for  according  to  oiir  experience  hair  continues 
to  grow  on  free  flaps  just  as  if  they  were  still  in  their  original  site. 
Thus  in  a  nine-year-old  boy  who  had  a  vascular  tumor  removed 

(see  p.  96),  and  whose  U2)per  lid  as  a  result  was  drawn  upward 
through  scar  contraction  and  fixed  immovably  in  this  position  (Fig. 
1.5,5,  Plate  27) .  after  excision  of  the  scar  and  loosening  of  the  remnant 
of  the  lid  the  defect,  which  just  covered  the  superciliary  ridge,  was 
covered  partly  by  a  pediculated  flap  from  the  forehead  (Fig.  156, 
Plate  27 )  and  partly  by  a  free  flap  taken  after  the  method  of  Krause 
from  the  hairy  scalp.     The  transplanted  flaps  healed  satisfactorily 

(Fig.  157,  Plate  27),  and  the  hair  continued  to  grow  undisturbed 
in  the  new  eyebrow.  Only  in  the  lateral  portion  of  the  flap  over  an 
area  about  2  cm.  long  did  the  growth  of  hair  cease.  Eight  months 
after  the  operation  the  right  upper  lid  appeared  normal  and  the  eye 
could  be  completely  closed.  The  hairless  portion  of  the  eyebrow  flap 
could  be  covered  easily  by  combing  over  it  the  long  scalp  hairs  of  the 
middle  portion,  as  the  transplanted  hair  in  the  new  site  showed  active 
growth. 

These  plastic  methods  for  upper  and  lower  lid  can  be  employed 
only  if  of  all  the  layers  at  least  the  conjunctiva  has  remained  intact. 
This  is  necessary  for  lining  the  new  flap.  But  if  the  destruction  in- 
volves all  the  layers,  a  new  lid  must  be  formed  clothed  within  and 
without  with  epidermis,  which  will  then  run  no  danger  of  shrinking. 
For  this  pin-pose  the  outer  covering  as  well  as  the  conjunctival  surface 
may  be  completed  out  of  the  portions  of  the  lid  which  remain,  or  from 
the  other  lid  of  the  same  side  if  this  is  retained  entirely.  In  order 
to  protect  the  ocular  surface  of  the  new-formed  lid  from  drying  and 
shrinking  as  far  as  possible,  free  flaps  of  epidermis  or  of  mucous  mem- 
brane may  be  transplanted  with  advantage. 

Attempts  to  replace  the  entire  lid,  in  so  far  as  the  functioning 
muscle  cannot  be  replaced,  result  as  a  rule  only  in  an  immovable,  stiff 
fold  of  skin.  For  the  lower  lid  this  result  may  be  satisfactory,  par- 
ticularly if  by  this  means  the  eye  may  be  saved.  In  place  of  the 
movable  upper  lid.  however,  only  a  useless  curtain  hangs  down  in  front 
of  the  eye,  which,  although  it  forms  a  protection  for  the  bulb,  never- 
theless acts  as  a  hindrance  to  sight. 

Anomalies  of  position  of  the  eyelid  may  be  corrected  readily  by 
simple  plastic  operations.  Ectropion  of  the  lower  lid  may  be  over- 
come b}^  cutting  out  a  triangle  from  its  conjunctiva  and  shortening 


Krause-Heymann-Ehrenfricd. 


Tab.  27. 


Plastic   from   forehead  to  correct  contraction  of  e\'elid, 
and   formation   of  ex'ebrow. 


Upper  tid  - 
drawn  itpwari! 


Flap 
Defect 


Fig.  150.  Defect  remaining  in  region  of  eyebrow. 


Fig.  155.  Scar  contracture  on  forehead  and  upper  lid. 


Old  scar 


Free  flap  trans- 
planted from  hairy 
scalp  to  eyebrow 
defect 


Rcbnian  Company,  New  \ork. 


Fig.  157.  Cosmetic  result  after  8  montlis. 


ECTROPION 


153 


the  lenfj-th  of  the  hd  mai-ffin,  as  are  shown  by  Figs.  TOO  and  IGl,  taken 
from  the  textbook  of  Czermak. 


Fig.  Ifil) 


Fig.  Uil 


Entropion  may  be  corrected  operatively  if  a  wedge  reaching  to  the 
conjunctiva,  the  base  parallel  to  the  edge  of  the  lid,  is  cut  out  of  the 
entire  width  of  the  lid.  The  base  of  the  wedge  is  at  the  skin  sm-face. 
The  suture  of  the  defect,  wliich  gaps  outwards,  results  in  a  turning 
outward  of  the  ciliated  margin. 


CHAPTER  9— SURGERY  OF  THE  EYE  AND  ORBIT 

^Vhile  surgery  of  the  eyeball  itself  must  remain  a  specialty,  every 
surgeon  is  at  times  forced  to  undertake  operative  procedures  on  the 
orbit  and  its  contents.  This  applies  particularly  to  such  diseases  as 
extend  from  neighboring  portions  of  the  face  or  from  the  protective 
coverings  of  the  eye  to  the  organ  of  sight  itself.  Only  the  procedures 
necessary  in  such  affections  will  be  treated  here. 

Fresh  injuries  which  result  in  a  complete  loss  or  destruction  of 
the  lids,  and  a  portion  of  the  ej^e  is  so  far  destroyed  that  sight  must 
be  considered  lost,  demand  operative  removal  of  the  bulb.  This  rule 
finds  its  justification  in  the  danger  of  sympathetic  ophthahnia,  which 
arises  in  the  other  eye  in  cases  of  purulent  infection.  In  severe  tiiber- 
ctilous  processes  in  the  conjunctiva  or  the  deeper  lying  coverings  of 
the  bulb  within  the  orbit  the  radical  operation  comes  likewise  under 
consideration. 

This  can  be  carried  out  after  either  of  two  methods.  Enucleation 
of  the  bulb  consists  in  shelling  out  the  eyeball  from  its  capsule,  Sv  pa- 
rating  the  conjimctival  sack,  muscles  and  optic  nerve  at  their  pomt 
of  attachment  to  the  bulb.  Exenteration  of  the  orbit,  on  the  other 
hand,  includes  a  complete  cleaning  out  of  the  bony  orbit;  the  orbital 
periosteum  is  removed  in  connection  with  all  of  the  surroundings  of 
the  bulb. 

ENUCLEATION   OF  THE   BULB 

is  indicated  in  infections  and  injuries  above  described  and  in  addition 
in  benign  timiors  and  in  malignant  tumors  the  boundaries  of  which 
have  not  overstepped  the  contents  of  the  bulb.  The  method  for  carry- 
ing it  out  may  be  demonstrated  by  the  following  case : 

A  thirty-three-year-old  workingman  had  lost  the  use  of  his  right 
eye  at  the  age  of  thirteen  years  from  a  bullet  wound.  The  ball  entered 
at  the  outer  canthus  and  remained  lying  in  the  depths  of  the  orbit. 
Vision  was  immediately  destroyed,  but  the  eyeball  was  retained. 
Although  the  patient  for  twenty  years  had  suffered  no  symptoms  in 
the  injured  eye,  four  weeks  before  entrance,  followqng  a  blow  on  the 
head,  headache  began  which  extended  on  both  sides,  laler  more  on  the 
left,  from  forehead  to  occiput. 

The  right  eye  showed  total  cataract  and  complete  amaurosis.     The 

154. 


Krause-Heymann-Ehrenfried 


Tab.  28. 


Enucleation   of  the  bulb. 


Su/ierior  rectus  muscle 


Border 

of 
cornea 


Retraction  of  upper  lid 


VC'ound  edge  at 
margin  of  cornea 


Fig.  162.  Dividing  the  cornea. 


Fig.  163.  Pulling  out  the  bulb  by  the  stump 
of  the  superior  rectus  muscle. 


Stump  of  superior  rectus 


Cut  edge  of 
conjunctiva 


Fig.  164.  l-urther  division  of  recti  muscles. 


Fig.  165.  Lifting  out  the  bulb. 


Rcbnian  Company,  New  York. 


ENUCLEATION  OF  THE  EYE  155 

tension  was  somewhat  lessened  and  the  eye  was  sensitive  to  pressure, 
although  the  motility  was  undistvirhed.  The  conjunetiva  of  the  lower 
lid  was  swollen  and  edematous  for  several  days  (Fig.  102,  Plate  28). 
The  right  infraorljital  nerve  at  its  exit  from  the  orhit  was  slightly 
sensitive.  X-ray  showed  the  hall  lying  in  the  back  of  the  orbit.  The 
left  eye  showed  slight  pericorneal  injection  and  was  also  painful  to 
pressure.  On  account  of  the  danger  of  sympathetic  ophthalmia  it 
was  decided  to  enucleate  the  useless  eye. 

The  lids  were  held  apart  with  two  fingers;  the  same  purpose  might 
be  accomplished  by  two  lid  retractors  or  a  spring  retractor.  At  the 
upper  edge  of  the  cornea  the  conjunctiva  of  the  bulb  was  raised  with 
forceps  and  cut  transversely  with  scissors,  and  the  superior  rectus 
was  dissected  out  with  a  few  strokes  of  the  scissors  (Fig.  162,  Plate 
28),  picked  up  with  a  blunt  hook,  and  separated  near  the  bulb.  The 
corneal  portion  of  the  tendon  was  seized  with  a  hemostat  (Fig.  163, 
Plate  28) ,  so  that  it  might  be  used  as  a  handle  in  further  manipulations. 
Then  the  conjunctiva  was  cut  in  a  circle  about  the  cornea,  and  the 
three  other  recti  were  similarly  separated  near  the  bulb  (Fig.  164, 
Plate  28).  Curved  scissors  were  then  introduced  on  the  medial  side 
behind  the  bulb,  and  the  optic  nerve  was  divided  near  to  its  entrance 
to  the  eyeball.  Then  the  bulb  became  loose  and  could  be  drawn  out 
from  the  orbit  (Fig.  165,  Plate  28).  Finally  the  tendons  of  the  two 
oblique  muscles  were  di\ided  at  their  insertions. 


""N, 


Fig.  I(i6 


The  muscle  stumps  were  retained  so  that  after  healing  an  artificial 
eye  could  be  moved  voluntaiily  in  the  retained  capsule;  the  edges  of 
tiie  conjunctiva  were  united  with  interrupted  sutures  (Fig.  166). 
Eight  days  after  the  enucleation  the  patient  was  discharged  with  a 
healed  wound  and  later  he  was  fitted  to  an  artificial  eye. 


136  SURGERY  OF  THE  EYE  AND  ORBIT 

The  advantage  of  emicleation  over  exenteration  lies  in  the  preserva- 
tion of  the  capsule  of  Tenon,  which  makes  possible  the  wearing  and  to 
a  certain  extent  the  movement  of  a  prothetic.  Artificial  ej'es  made 
of  glass  may  be  emjjloyed  that  are  so  deceptive  that  they  do  not  affect 
the  expression. 

EXENTERATION  OF  THE  ORBIT 

is  indicated  in  all  malignant  tumors  which  originate  in  the  outer  por- 
tions of  the  eye  or  in  its  immediate  neighborhood  as  well  as  in  pene- 
trating infectious  processes  and  in  progressive  celhditis  of  the  orbit. 
As  all  the  soft  parts  of  the  orbit  are  to  be  cleaned  out,  its  inner  asj^ect 
may  be  carefully  examined  in  order  that  infected  areas  of  bone  may 
be  recognized.  The  extensive  wound  surface  is  covered  by  a  flap  from 
the  forehead  after  the  method  of  Kiister,*  or  if  the  upper  and  lower 
lids  are  to  be  retained,  it  may  be  closed  by  uniting  them. 

In  this  w'ay  in  a  series  of  cases  of  perforating  tuberculosis  of  the 
orbit  and  of  purulent  phlegmon  both  lids  have  been  spared  at  the 
edges  of  the  orbit.  For  cosmetic  reasons  the  preservation  and  suture 
of  the  lids  after  removal  of  the  mucous  membrane  and  ciliated  edge 
is  more  favorable  than  turning  down  a  flap  built  from  the  skin  of  the 
forehead.  The  inverted  scar  at  the  healed  edges  of  the  lid  is  so  slightly 
noticeable  that  usually  an  eyeshade  does  not  have  to  be  worn. 

EXENTERATION   OF   THE   ORBIT   WITH    PRESERVATION   OF   THE    LIDS 

In  a  twenty-eight-year-old  woman  a  year  before,  on  account  of 
tuberculosis  of  the  right  orbit  with  practically  complete  loss  of  vision, 
resection  of  all  the  involved  portions  of  bone  was  carried  out.  After 
an  improvement  lasting  a  few  months,  the  vision  suddenly  vanished 
with  an  appearance  of  marked  choroiditis.  The  marked  exophthalmos, 
headache  and  the  inflamed  appearance  of  the  conjunctiva,  as  well  as 
the  swelling  over  the  orbital  bones,  spoke  for  a  lighting  up  of  the 
tuberculosis  and  its  spread  to  involve  the  tunics  of  the  eyeball.  Ac- 
cordingly, exenteration  of  the  orbit  was  decided  upon. 

The  fissure  of  the  lids  was  extended  laterally  with  a  knife  to  the 
outer  edge  of  the  orbit,  and  at  the  same  time  a  tuberculous  fistula  in 
the  outer  canthus  was  surrounded  by  the  incision  (Fig.  167,  Plate  29) . 
The  lids  were  pulled  apart  with  sharp  hooks  and  the  markedly  altered 
edematous  conjunctiva  was  separated  from  the  inner  siu'face  of  the 
lids  with  a  knife  down  to  the  upper  and  lower  edges  of  the  orbit. 

•Zeiitnil.   f.   Chir.,   1890.  Xr.  2. 


Krause-Hevmann-Ehrenfried. 


Tab.  29. 


Exenteration   of  the   orbit,   retaininij-  the   lid.s. 


Tnberciilou 
fist ti In,  to 
Edees         *''  ^-^f^ist'd 
of  liileral  1 


Orbital  fiit 


Raspatory 


Fig.  107.  A  transverse  incision  is  made 
outward  throngiitlioontercantlms,  to 
give  better  exposure,  and  an  incision 
through  conjunctiva  is  made  around  the  "lobe 


Optif  nerve 

Fig.  108.  Luxation  of  orbital  contents. 


V 


Ciliary  inaririii 


J 


iihriTuloiis  irnirir//ti/ioris 


Fig.  loy.  Removal  of  tuberculous  granulations. 


t'' 


Fig.  170.  Removal  of  ciliary  margin. 


Iodoform 
packing 


Suture  of  freshened  edges  of  lids 

Fig.  171.  Appearance  at  end  of  operation. 


lebinan  Company,  New  York. 


EXENTERATION  OF  TFIE  ORBIT  157 

Tlien  tlie  periosteum  was  incised  around  the  orbit  down  to  bone,  and 
witli  a  wide  raspatory  separated  from  the  bony  wall  of  the  orbit  on 
all  sides  until  it  was  possible  to  dislocate  outwards  the  entire  content 
of  the  orbit  (Fig.  1(»8,  Plate  20).  This  brought  to  view  the  optic 
nerve  under  tension,  together  with  the  ophthalmic  artery  and  vein, 
as  the  only  structures  holding  the  eyeball,  and  these  were  cut  willi 
scissors  at  the  optic  foramen.  The  hemorrhage  as  usual  was  controlled 
by  pressure,  and  it  was  unnecessary  to  seize  and  tie  the  ophthalmic 
artery  in  the  apex  of  the  funnel.  Thereupon  all  tuberculous  granu- 
lations and  necrotic  bone  of  the  orbit  were  removed  with  a  curette 
(Fig.  169,  Plate  29),  also  a  portion  of  the  upper  maxilla  had  to  he 
dissected  out  on  account  of  tuberculous  infiltration. 

In  order  to  cover  in  the  large  cavity  which  resulted,  both  lids  were 
made  use  of.  The  ciliated  edges  were  removed  (Fig.  170,  Plate  29) 
and  the  freshened  margins  as  well  as  a  part  of  the  lateral  incision 
were  imited  by  interrupted  sutures  (Fig.  171,  Plate  29).  Since  the 
case  was  one  of  tuberculosis,  the  orbital  funnel  was  stuffed  with  iodo- 
form gauze,  the  end  of  which  was  brought  out  at  the  outermost  corner 
of  the  lateral  incision.  After  five  days  the  packing  was  removed,  so 
that  the  already  healed  lid  edges  could  lie  against  the  wall  of  the  orbit. 
After  eight  days  more  the  patient  was  discharged  relieved.  As  a 
result  of  the  maintenance  of  the  lids  the  deformity  was  so  slight  that 
the  girl  did  not  have  to  wear  an  eye  shield. 

EXENTERATION    OF   THE   OKBIT    WITH    REIIOVAI,   OF   THE    I.inS 

If  the  lids  are  involved  in  the  disease,  as,  for  instance,,  in  malignant 
growths,  and  particularly  in  spreading  epithelioma  at  the  inner  can- 
thus,  they  must  be  removed  as  well  as  soft  parts  and  bone  in  conjunc- 
tion with  the  contents  of  the  orbit.  There  results  a  wide  wound 
surface  with  an  irregular  base,  which,  after  the  technique  of  Kiister, 
is  covered  over  with  a  pediculatcd  flap  from  the  forehead  or  temple. 
After  this  operation  an  eyeshade  or  a  dark  or  ground  glass  must  be 
worn. 

Since  superficial  skin  cancer  in  the  region  of  the  canthus  or  on  the 
lids  themselves  usually  extends  slowly,  ordinarily,  in  clearly  defined 
cases  of  cancerous  infiltration  and  ulceration,  excision  in  sound  tissue 
with  maintenance  of  the  eyeball  suffices.  Only  the  involved  portion 
of  the  lid  has  to  be  removed,  as  shown  on  page  102.  But  if  the  disease 
has  extended  to  the  conjunctiva  of  the  iimcr  canthus  or  to  the  bulb, 
exenteration  of  the  orbit  is  indicated,  in  addition  to  extirpation  of  the 


158  SURGERY  OF  THE  EYE  AND  ORBIT 

lids,  even  when  vision  is  unimpaired.  The  operative  procedure  is 
demonstrated  l)v  the  follo\vin<>-  case: 

In  a  thirty-one-year-old  Russian,  who  in  his  own  country  had  heen 
operated  upon  about  fifteen  times,  a  crater-like  ulcer  about  32  nim. 
deep  Avith  hard  edges  was  located  in  the  left  inner  canthus.  The  in- 
flamed median  surface  of  the  eyeball  formed  the  outer  boundary  of 
this  crater.  In  addition  there  appeared  when  the  eyes  were  shut  a 
carcinomatous  ulcer  (Fig.  172,  Plate  30)  close  to  the  suj^erior  edge 
of  the  orbit.  Although  the  eye  possessed  satisfactory  vision,  it  had 
to  be  sacrificed ;  likewise  it  was  necessary  to  remove  at  least  the  inner 
halves  of  the  lids.  The  woimd  cavity  which  resulted  from  exenteration 
of  the  orbit  and  removal  of  half  the  lids  was  too  large  to  allow  of 
covering  over  with  the  rest  of  the  lids  and,  therefore,  before  extirpating 
the  carcinoma,  the  incisions  necessary  for  the  skin  plastic  had  to  be 
planned  in  advance. 

The  lids  (Fig.  173,  Plate  30)  were  split  vertically  at  the  junction  of 
the  outer  and  middle  thirds.  They  were  dissected  back  laterally  and 
the  periosteum  at  the  outer  edge  of  the  orbit  was  divided  down  to 
bone.  From  this  point  the  cleaning  out  of  the  bulb  and  periosteum 
of  the  orbit  was  carried  out  with  a  raspatory.  But  on  palpation 
of  the  lids  which  had  just  been  split  (Fig.  172,  Plate  30)  small  lumps 
could  also  be  felt,  and  so  each  lid  was  removed  in  its  entirety  by  an 
incision  following  the  edge  of  the  bony  orbit.  In  this  way  the  car- 
cinomatous, ulcer  was  surroimded  by  two  incisions,  which  met  at  a 
point  over  the  bridge  of  the  nose  (Fig.  174,  Plate  30).  In  removing 
the  orbital  contents,  beginning  at  the  outer  side,  by  means  of  the 
raspatory,  naturally  some  of  the  carcinoma  oii  the  medial  surface 
of  the  orbit  was  left  behind.  The  extirpation  of  this  and  several  sus- 
picious areas  of  bone  was  readily  accomplished,  after  the  orbit  Avas 
emptied.  Re-examination  showed  that  the  carcinoma  had  extended 
over  the  inner  surface  of  the  orbit  (Fig.  17.),  Plate  30).  The  supra- 
orl)ital  nerve,  which  lay  free  for  about  3  cm.,  Avas  resected. 

In  chiseling  off  the  nasal  bone  and  the  nasal  process  of  the  frontal 
bone  the  frontal  sinus  was  laid  open  (Fig.  176,  Plate  31),  and  after 
the  removal  of  the  roof  of  the  orbit  the  dura  mater  Avas  exposed. 
JNIedially  likcAvise  the  bone  had  to  be  removed  for  a  considerable  ex- 
tent. As  the  frontal  process  of  the  upper  jaw  was  remoA'ed  Avith  the 
chisel  (Fig.  177,  Plate  31),  and  as  a  result  the  antrum  was  opened 
Avide,  the  entire  left  nasal  cavity  A\'as  exposed  (Fig.  178,  Plate  31), 
and  the  medial  boundarA'  of  the  Avound  Avas  formed  bv  the  turbinates. 


Krause-Hf^inannEhrcnfried. 


Tab.  30. 


Exenteration   ol    mlMt   with   renioxal   ot    lids.    1. 


Caicinonuitoiis  ulcer 


Carcinoma  at 
inner  canthiis 


Fig.  172.  Carcinoma  at  iniu-r  canthus  and  on  upper  lid. 


Upper  lid 
split  vertically 


Fig.  173.  Incising  periosteum  along  outer 
margin  of  orbit. 


Incision  alon^  upper 
margin  of  orbit 


Corciuoma 


Fig.  17-1.   Removal  of  lids. 


Carcinoma 


Orhit 


Fig.  17t.  Kxenteration  of  orhit  comjileted. 


Su/tmorhifal  nerve 


l)iiian  ('ompaify,  New  ^'f^rk. 


Krause-Heymann-Ehrenfried. 


Tab.  31. 


Exenteration  and  resection   of  orbit.   U. 


Infraorbital 
nerve 


Frontal  sinus 


Dura 
mater 


Fig.  176.  Resection  of  roof  of  orbit. 


Fio.  177.  Resection  of  frontal  process  of  superior  niaxilla. 


Frontal  sinus 


Septum  of  nose 


Lower  and  tniddlc  tnrltiiiates 

Fig.  178.  Exposure  of  Nasal  cavity. 


Dura  mater 


Sphenoid  cells 


Vomer 
Xntruni  of  f/ig/imore 


Fig.  179.  Packing  begun;  shows  extent 
of  wound. 


ebinan  Company,  New  York 


Knuise-Hevmann-rhreiifiied. 


Tab.  32. 


Plastic  covering  of  exenteratccl   orbit  after  Kiister.  III. 


Pedicle 


Defect  in  forehead 


Pedi 


Provisional 
packing 


Suture  at  outer  canthus 

Fig.  180.    Cutting 
fiefect  forehead. 


Flap  implanted  over  orbit 

Fig.  182.  Sewing  in  the  flap,  and  suture 
of  the  secondary  defect. 


Unclosed 
portion  of 

defect  of 
forehead 


Defect  in  forehead  closed 
by  scar  tissue 


Rebman  Company,  New  York. 


Fig.  183.  Wounds  iieaicd    \  weeks  after  operation. 


EXENTERATION  OF  THE  ORBIT  159 

These  also  showed  areas  which  were  susj)icious  of  carcinoma  and  were 
removed  in  conjunction  with  the  ethmoid  cells  and  the  walls  of  the 
sphenoid  cells,  as  well  as  a  portion  of  the  mucous  membrane  of  the 
vomer.  The  infraorbital  nerve  was  in  this  process  exposed  and  re- 
sected. 

From  above  downward  the  inferior  meatus  and  the  antrum  were 
■packed  with  vioform  <>-auze  (Fi^.  179,  Plate  31),  in  order  that  no 
blood  could  run  down  into  the  pharynx  and  be  insufflated.  From  the 
depths  of  the  sphenomaxillary  fossa  a  branch  of  the  internal  maxillary 
artery  bled.  It  was  packed  with  gauze  impregnated  with  iodoform 
in  order  to  prevent  decomposition,  because  here  the  packing  had  to 
remain  for  a  considerable  length  of  time;  this  packing  was  differ- 
entiated from  tile  other  strips  of  gauze  by  tying  silk  about  the  end. 
Likewise,  the  exposed  surface  of  the  dura  was  protected  with  iodoform 
gauze,  the  end  was  knotted  and  was  carried  out  through  the  left  nasal 
orifice  above  the  other  two  strips  (Fig.  179,  Plate  31). 

The  large  wound  cavity  could  be  partially  closed  at  the  outer  can- 
thus  (Fig.  180,  Plate  32)  ;  but  the  tension  was  too  great  to  allow  of 
more  than  three  interrupted  sutures.  The  rest  of  the  defect  measured 
55  mm.  from  right  to  left  and  32  mm.  from  above  downward.  This 
surface  was  covei-ed  with  a  skin-periosteum  flap  from  tiie  forehead, 
the  pedicle  of  which  lay  at  the  right  side  of  the  root  of  the  nose,  and 
the  upper  end  came  to  a  point  so  that  it  would  fit  into  the  defect 
(Fig.  181,  Plate  32).  The  flap  Avas  sewed  in  by  interrupted  silk, 
leaving  no  drainage  in  the  orbit  (Fig.  182,  Plate  32).  Finally  the 
secondary  defect  on  the  forehead  was  closed  after  underminina;  the 
edges,  except  for  a  small  area  2  cm.  long  and  a  few  mm.  wide. 

At  the  first  dressing  on  the  second  day  after  operation  the  drains 
were  pulled  out  slightly  through  the  nose.  Fight  days  later  the  more 
su])erficial  tam])on  lying  in  the  ncighboi-hood  of  the  orbit  was  com- 
pletely removed  and  the  iodoform  ])ackiiig,  which  was  recognized 
by  the  silk  tie  and  the  knot,  was  somewhat  shortened.  Every  second 
day  these  were  drawn  out  somewhat  until  they  were  completely  re- 
moved on  the  twenty-second  day  after  operation.  The  small  gap  in 
the  forehead  had  filled  in  rapidly  with  granulations  and  had  mean- 
while epidermatized,  so  that  the  patient  on  this  day  could  be  dis- 
charged healed  (Fig.  183,  Plate  32).  Up  to  this  time  if  the  patient 
were  touched  with  forceps  upon  the  flap,  the  sensation  was  always 
localized  on  the  forehead  above  the  orbit;  contact  directlv  at  the  base 


160  SURGERY  OF  THE  EYE  AND  ORBIT 

of  tlie  flap  alone  was  rightly  localized ;  only  in  time  was  correct  locali- 
zation learned. 

kronlein's  osteoplastic  resection  of  the  temporal  wall 

OF  the  orbit 

Tumors  lying  behind  the  bull),  for  instance,  those  of  the  optic  nerve, 
and  inflammatory  infections  of  the  orbit,  such  as  cellulitis  and  tubercu- 
losis, may  sometimes  be  overcome  surgically  without  the  necessity  of 
sacrificing  the  eyeball.  In  order  to  accomplish  this,  the  outer  wall 
of  the  orbit  is  resected  osteoplastically  after  the  method  of  Kronlein, 
and,  if  necessary,  the  capsule  of  Tenon  is  split.  x\fter  turning  back 
the  bony  parts  one  can  penetrate  into  the  depths  of  the  orbit  as  far 
as  the  optic  nerve  and  carry  out  operative  procediu'es  here  in  full  view. 

Naturally,  these  conservative  methods  can  only  find  application  if, 
as  was  explained  in  the  previous  section,  no  indication  exists  for  the 
removal  of  the  eyeball,  for  instance  in  limited  benign  tumors  in  the 
orbit,  whether  arising  from  bone,  connective  tissue,  muscle  or  optic 
nerve.  Kronlein  devised  this  method  for  the  removal  of  a  laterally 
situated  dermoid  cyst.  It  seems  to  be  indicated  also  if  tuberculous 
masses  have  penetrated  the  bony  wall  of  the  orbit,  and  cause  the  bulb 
to  project  without  involving  it,  or  if  a  cellulitis  has  spread  over  the 
floor  of  the  orbit. 

In  a  twenty-eight-year-old  young  woman  who  had  had  a  tuberculous 
abscess  over  the  zygoma  incised  a  year  before,  the  Kronlein  operation 
was  performed  in  order  to  put  a  stop  to  the  rapid  loss  of  vision  which 
was  resulting  from  proliferation  of  tuberculous  granulations  behind 
the  bulb.  X-rays  showed  no  bony  changes.  Retinal  examination  of 
the  right  eye  showed  papillitis  with  advancing  optic  atrophy.  The 
eyelids  were  swollen  and  edematous  (Fig.  18.5,  Plate  33),  and  there 
was  present  a  marked  degree  of  exophthalmos.  All  movements  of  the 
eye  were  present,  but  limited. 

The  skin  was  divided  outward  from  the  middle  of  the  right  eyebrow 
in  crescentic  fashion  as  far  as  the  outer  corner  of  the  orbit,  and  from 
this  point,  following  the  Kocher  modification  for  the  purpose  of  avoid- 
ing the  branches  of  the  facial  nerve,  contimied  transversely  outward 
(Fig.  185,  Plate  33).  After  dividing  the  periosteum  at  the  edge  of 
the  orbit,  the  bulb  in  all  its  coverings  could  be  so  far  loosened  from 
the  outer  wall  of  the  orbit  with  a  raspatory  (Fig.  186.  Plate  33)  that 
the  instrument  reached  in  the  depths  to  the  inferior  fissiu-e  of  the 
orbit.     There  was  very  little  bleeding,  but  even  at  moderate  depths 


Krause-Heymann-Ehrenfried.  j^^    -jj 

Kroenlein's  osteoplastic  resection   of  the  tcm])oraI   wall   of  the  orbit. 


Edematous 

eyelith 


Outer  and 
lower  corner  of 
bony  orbit     ~ 


Fig.  185.  Modified  Kocher  skin 
incision. 

Tumor-lihf  tuberculous  f^rnnulatrons 


Retractor  on 

lower  wound 

edge 

Fig.  186.  The  bulb  \x'itli  its  coverings  intact  is  lifted  away  from  the 
external  orbital  wall. 


•  -  ■*'  Tuberculous  srrauulations 

Fig.  187.  Making  the  bony  incisions. 


Outer  margin  of  orbit  with 
soft  parts  attached 


Rebmaii  Company,  New  York. 


Tuberculous  granulationh 

Fig.  188.  The  bony  wedge  is  displaced  outward. 


RESECTION  OF  THE  TEMPORAL  WALL  OF  THE  ORBIT       161 

hard  tuniorlike  granulations  appeared,  which  resembled  in  form  white 
beans  (Fig.  187,  Plate  tV.i) . 

During  the  freeing  up  of  the  periosteum  within  the  orbit  all  pull 
on  the  upper  outer  edge  of  the  skin  was  avoided,  in  order  that  the 
soft  parts  might  not  become  loosened  from  tiie  bone.  But  on  the 
other  hand  the  wound  had  to  be  pulled  strongly  downward  to  expose 
partially  the  lower  margin  of  the  orbit  (Fig.  186,  Plate  33).    There- 


:Bane  incision 
:  Skin  incision 


Fig.  184 

upon  the  outer  wall  of  the  orbit  was  chiseled  through  abo\e  and  below 
(Fig.  184)  and  the  bony  incision  was  carried  in  the  direction  of  the 
raspatory,  which  was  stuck  in  the  lower  orbital  fissure.  Above,  the 
chisel  was  introduced  just  over  the  suture,  wliich  could  be  palpated 
between  frontal  l)()Me  and  zygoma;  below,  at  the  level  of  the  zygoma. 
A  portion  of  the  zygoma  was  removed  by  the  lower  cut.  In  this 
way  one  could  form  a  bony  wedge  from  the  lateral  wall  of  the  orbit, 
which,  in  connection  with  muscle  and  skin,  could  ])e  turned  backwards 
over  the  temi)le   (Fig.  188,  Plate  33). 

There  now  appeared  in  the  orbit  tumor-like  tuljcrculous  granuhi- 


162  SURGERY  OF  THE  EYE  AND  ORBIT 

tions,  which  were  particularly  luxuriant  on  the  floor  and  along  the 
inferior  orbital  fissure.  These  were  removed  with  a  curette  as  well  as 
soft  areas  of  bone,  with  the  result  that  the  antrum  was  opened.  As 
there  was  no  indication  for  incising  the  periosteum  of  the  orbit  laterally, 
thus  exposing  the  external  rectus  as  well  as  the  optic  nerve  or  the  pos- 
terior surface  of  the  bulb,  the  skin-bone  flap  was  replaced  after  a  strip 
of  iodoform  gauze  and  a  thick  drainage  tube  were  left  behind  down 
to  the  position  of  the  removed  granulation  masses.  The  wound  at  the 
outer  canthus  was  closed  by  a  suture,  including  at  the  same  time  skin 
and  periosteum.  Five  days  later  the  gauze  and  a  few  days  after  that 
the  drainage  tube  was  removed.  The  bone  healed  in  by  primary 
imion.  The  removal  of  the  masses  of  granulation  tissue  had  no  effect 
on  the  vision.  The  extrusion  of  the  bulb  and  the  edema  of  the  lids 
did  not  completely  disappear.  Six  months  later,  on  account  of  ad- 
vancing tuberculosis,  the  upper  jaw  had  to  be  resected. 

TREATMENT  OF   CELLULITIS   OF  THE   ORBIT 

Through  temporary  resection  of  the  outer  wall  of  the  orbit  foci  of 
pus  in  the  orbit  may  be  exposed.  In  addition  to  the  regular  symptoms 
of  sepsis,  phlegmon  of  the  orbit  expresses  itself  in  a  protrusion  for- 
ward and  limitation  of  motion  of  the  eyeball,  as  well  as  in  swelling 
and  reddening  of  the  lids.  Purulent  infiltrations  develop  from  in- 
fected wounds  which  are  situated  near  the  eye  or  the  orbital  veins,  and 
sometimes  result  in  empyema  of  the  accessory  cavities  of  the  nose. 
The  prognosis  is  always  unfavorable  because  there  is  danger  that  the 
phlegmon  may  extend  to  the  brain  and  its  envelope.  On  the  other 
hand,  the  prognosis  is  more  favorable  if  the  abscess  is  the  result  of  a 
penetrating  foreign  body. 

Small  incisions  at  the  canthus  or  at  the  upper  orbital  margin  do  not 
suffice  to  expose  all  the  infiltrated  area :  moreover,  satisfactory  drain- 
age cannot  be  obtained  from  such  incisions.  Orbital  jihlegmon  and 
abscess  must  be  opened  much  more  widely.  The  following  observa- 
tion shows  how  the  Kronlein  oj^eration  allows  free  approach  to  the 
depths  of  the  orbit: 

A  forty-year-old  woman  was  brought  into  the  hospital  in  a  state  of 
coma  with  all  signs  of  phlegmon  of  the  orbit  and  secondary  brain 
abscess.  At  the  inner  upper  edge  of  the  orbit  was  situated  a  wound 
of  the  soft  parts  out  of  which  a  drainage  tube  and  iodoform  gauze 
projected.  The  upper  lid  was  chemotically  swollen  in  the  highest 
degree.     In  order  to  open  wide  the  phlegmon  the  outer  wall  of  the 


CELLULITIS  OF  THE  ORBIT  16:J 

orbit  was  resected  after  the  nietliod  of  Kronlcin,  usinir  the  Kocher 
incision  to  avoid  the  facial  hranches. 

In  l()osciiiii<i-  up  the  periosteum  of  tlie  orbit  with  the  fiii<ifer  foul- 
snielhii<:f  ichorous  pus  Avelled  up,  which,  bein<)'  wiped  away,  kept  re- 
appearing at  the  inner  up])er  corner  of  the  orbit  under  tlie  iloor  of 
the  anterior  fossa.  As  tlic  periosteum  of  the  orbit  was  incised  in  the 
liorizontal  plane  and  the  contents  exposed  we  were  struck  by  the  dis- 
colored appearance  of  the  lacrimal  gland,  the  fat  and  the  rectus  ex- 
ternus;  and  on  introducing  the  finger  into  the  orbital  fat  there  was 
found  only  a  turl)id  serous  infiltration,  but  no  fluid  pus. 

After  exposing  the  orbit  the  anterior  fossa  was  trephined  above 
the  supraor])ital  ridge,  o])ening  uj)  the  abscess  of  the  frontal  lobe.  Xo 
anesthesia  was  necessary  during  the  entire  operatif)n,  since  the  patient, 
being  in  complete  coma,  felt  no  pain.  She  died  the  day  after  the 
operation  without  recovering  consciousness. 


CHAPTER  10— STTRGERY  OF  THE  EAR 

INJURIES  AND  DISEASES  OF  THE  EXTERNAL  EAR 

Injuries  of  the  external  ear  for  the  most  part  demand  but  little  special 
surgical  interest;  their  treatment  follows  the  rules  of  general  surgical 
practice.  Likewise  operations  for  infection  or  small  tumors  in  the 
soft  parts  and  cartilaginous  plates  of  the  shell  of  the  ear,  or  in  the 
external  meatus  do  not  depart  from  the  principles  of  treatment  of 
similar  affections  in  other  parts  of  the  head. 

In  a  thirty-five-year-old  bookbinder  an  epithelial  growth  about  the 
size  of  a  cherry  (Fig.  189,  Plate  34)  on  the  upper  half  of  the  right 
concha,  which  had  apparently  developed  from  a  wart,  was  excised 
in  the  form  of  a  wedge  under  local  anesthesia.  Since  the  cartilage  as 
usual  projected  beyond  the  upper  and  lower  cut  surfaces,  it  was  pulled 
out  as  far  as  possible  Avith  forceps,  but  without  tearing  it  from  its 
surrounding  tissue,  and  with  curved  scissors  the  projecting  edge  was 
removed  (Fig.  190,  Plate  34).  Then  the  cartilage  was  united  by  two 
fine  catgut  sutures  (Fig.  191,  Plate  34),  and  the  skin  with  six  inter- 
rupted sutures  of  silk  (Fig.  192,  Plate  34).  A  dry  sterile  bandage 
was  applied  with  adhesive  straps  to  hold  it  in  place,  and  the  dressing 
"was  changed  in  five  days:  the  wound  liealed  by  first  intention  and  after 
ten  days  tlie  patient  was  discharged  from  the  out-jjatient  clinic. 

In  resection  of  the  shell  of  the  ear  it  is  usually  unnecessary  to  replace 
the  loss  of  substance  by  the  help  of  any  particular  plastic  method. 
For  the  movability  of  the  tissues  makes  it  possible  to  repair  the  defect 
by  direct  suture  of  tlie  wound  edges.  To  be  sure,  attempts  have  been 
made  to  replace  the  shell  of  the  ear  after  complete  destruction  by  the 
use  of  skin  from  the  temporal  region,  but  tlie  results  obtained  can 
hardly  be  considered  satisfactory  in  any  regard, — cosmetically,  because 
there  residted  only  a  misfoi-med  flap  of  skin,  which  in  its  shape  pos- 
sessed no  similarity  to  the  fumiel-like  conclia, — functionally,  because 
the  flabby  flap  of  skin  was  unable  to  replace  physiologically  the  first 
element  in  the  sound-transmitting  apparatus. 

Among  diseases,  closure  of  the  external  auditory  canal  may  be  re- 
lieved by  surgical  methods,  if  the  hearing  is  disturbed  or  tlie  removal 
of  secretion  is  impeded.    Such  a  condition  may  result  from  furuncles 

164 


Krause-Heymann-Ehrenfried. 


Tab.  34. 


Wedge-shaped  resection  of  a  portion  of  the  shell   of  the  ear, 


Angiosarcoma 


Helix 


Fig.  189.  Incision,  w  itli  scissors. 


Cartilage  . — 


Cartilage 


Fig.  190.  Removal  of  excess  of  cartilage. 


Fig.  191.  Suture  of  Cartilage. 


Helix 


Fig.  192.  Skin  suture. 


Rebman  Company,  New  York. 


CERUMEN  AND  FOREIGN   BODIES  166 

which  (leveloj)  in  the  hair  follicles  of  the  canal.  They  cause  acute  pain, 
I^articulai'ly  if  the  infiltration  extends  down  to  the  perichondrium,  and 
moi-cover  the  acuteness  of  lieariiifr  is  ordinarily  interfered  with,  be- 
cause the  canal  as  a  result  of  swelling-  of  the  walls  is  narrowed  or 
even  entirely  closed.  Early  and  deep  incisions  of  the  reddened  and 
swollen  jjlaces  followed  by  light  packing  with  moist  gauze  usuallj^ 
overcomes  the  symptoms  in  a  short  time. 

Complete  closure  of  the  external  auditory  canal  may  take  place  as 
the  result  of  the  collection  of  ear-wax.  This  leads  finally  to  the  de- 
velopment of  a  plug  of  impacted  cerumen,  which  is  composed  of  the 
insi)issated  secretion  of  the  skin  glands,  of  epithelium,  and  of  foreign 
bodies  which  have  penetrated  from  without.  Tiie  symptoms  consist 
in  a  dimimition  of  hearing  and  a  feeling  of  fulness  in  the  ear.  ]Me- 
chanical  closure  of  the  external  canal  occurs  not  infrequently,  par- 
ticularly in  children,  from  the  introduction  of  objects  into  the  ear 
which  stick  fast.  They  may  remain  without  reaction,  but  more 
usually  they  lead  to  severe  inflammatoiy  changes  and  abscess  forma- 
tion in  the  deeper  lying  parts  of  the  ear. 

In  order  to  render  visible  such  foreign  bodies,  as  well  as  all  external 
changes  as  far  as  the  drum,  the  shell  of  the  ear  must  be  pulled  back- 
ward and  ujjward,  so  as  to  straighten  out  the  external  auditory  canal. 
If  this  simple  jjrocedure  does  not  succeed,  the  canal  should  be  exam- 
ined with  an  ear  speculum. 

If  there  is  obstruction  to  the  introduction  of  instruments,  an 
attempt  should  be  made  through  irrigation  of  the  canal  with  lukewarm 
boric  acid  solution  or  through  instillation  with  hydrogen  dioxid  to 
wash  out  the  mechanical  obstruction.  To  enter  the  auditory  canal  at 
once  with  an  ear  spoon,  hook  or  forceps  is  dangerous,  because  in  work- 
ing in  the  dark  with  instruments  the  drum  membrane  may  be  readily 
injured  and  the  middle  ear  infected.  Instruments  should  only  be 
employed  after  repeated  irrigations  or  the  introduction  of  softening 
sohitir)iis  have  been  without  result.  If  the  foreign  body  is  broken 
up,  it  may  be  easily  seized  with  a  small  instrument  and  drawn  out. 

In  an  eight-year-old  girl  the  ])oint  of  a  dance-order  ])encil  almut 
2  cm.  long  was  extracted  after  it  had  been  situated  in  the  exteriuil 
canal  for  several  days.  The  girl  had  attempted  to  remove  a  plug  of 
absorbent  cotton  with  the  aid  of  the  small  pencil,  because  as  a  result 
of  the  otitis  media  which  was  present,  it  had  caused  marked  irritation. 
In  this  way  the  ])oint  was  broken  off,  and  was  found  on  examination 
in  an  indistinct  stickj^  mass  lying  between  the  much-swollen  walls 


166  SURGERY  OF  THE  EAR 

of  the  canal.  The  first  attempt  to  remove  the  visible  pencil  point 
caused  great  pain.  Thereupon  a  cold  compress  of  alcohol  and  water 
was  applied  for  twenty-four  hours,  causing  a  visible  reduction  in  the 
swellinsr.  The  mass  of  secretion  was  then  washed  out  with  boric  acid 
solution,  until  a  larger  portion  of  the  broken-off  tip  was  visible.  With 
a  right-angle  forceps  similar  to  the  instrument  for  seizing  the  iris,  the 
loosened  lead  could  be  seized  and  withdrawn.  After  the  rather  pain- 
ful removal  a  little  blood  trickled  out  of  the  meatus.  A  few  days 
later  the  wad  of  absorbent  cotton,  which  had  remained  in  the  ear  for 
some  time,  and  had  been  softened  up  by  daily  irrigation  with  warm 
water  and  tlie  introduction  with  a  dropper  of  a  1  per  cent,  solution  of 
sodium  carbonate,  could  be  removed.  The  meatus  was  in  this  case, 
as  in  similar  cases,  filled  with  a  plug  of  gauze. 

Swollen  legumins,  such  as  hcans  and  peas,  are  best  removed  with 
the  help  of  a  small,  sharp  hook,  which  is  introduced  parallel  to  the 
wall  of  the  canal  until  the  hook  is  behind  the  object,  and  is  then  turned 
to  a  perpendicular  position  and  withdrawn. 

PURULENT  IXFLAMJIATION   OF   THE  MIDDLE  EAR 

Of  the  diseases  of  the  middle  ear,  retention  of  pus  in  the  tympanic 
cavfty  and  its  neighborhood  demands  particular  interest  and  usually 
inmiediate  help  on  the  part  of  the  surgeon,  for  delay  in  this  disease 
endangers  not  only  hearing,  but  may  involve  loss  of  life.  For  this 
reason  the  most  practical  methods  for  exposing  foci  of  pus  originating 
in  the  tympanic  cavity  will  be  described. 

Retained  pus  in  the  tympanic  cavity  causes  severe  pain,  and  in 
addition  to  the  ordinary  symptoms  of  infection,  there  appears,  as  a 
rule,  difficulty  in  hearing.  The  drum  examined  through  a  speculum 
shows  marked  vascular  injection,  frequently  tumor-like  bulging,  and 
in  advanced  cases  before  perforation,  yellowish,  greasy  spots  elevated 
above  the  level  are  visible.  The  light  reflex  disappears  with  the  be- 
ginning of  bulging,  as  well  as  the  light  streak  in  the  upper  anterior 
quadrant,  which  marks  the  attachment  of  the  hammer.  Taking  these 
symptoms  together,  an  outlet  for  the  pus  must  be  made  by  incising 
the  drum.    This  is  accomplished  by 

PARACENTESIS 

which  is  carried  out  with  a  small  scalpel  or  a  paracentesis  knife  with 
an  elbow,  on  the  well-lighted  and  clearly  visible  drum.     The  stroke 


PAKACEXTESIS  167 

of  the  knife  is  made  in  an  oblique  direction  in  the  lower  posterior 
quadrant.  The  exit  of  pus  is  encouraged  by  irrigation  with  a 
sterile  or  weakly  antiseptic  solution  under  very  low  pressure. 
Since  paracentesis  causes  pain,  it  must  usually  be  carried  on  under 
anesthesia.  The  incision  in  the  drum  may  be  either  too  long 
or  too  short.  An  incision  several  mm.  long  makes  tlie  flow  of  pus 
more  ready,  while  through  a  simple  puncture,  such  as  is  practiced  by 
many,  in  favorable  cases  the  pus  only  exudes  drop  by  drop.  As  a 
result  of  the  inflammatory  swelling  of  the  drimi,  incisions  which  are 
too  small  close  up  again  readily. 

Tiie  danger  which  exists  from  the  retention  of  pus  behind  the  drum 
lies  chiefly  in  the  open  communication  of  the  middle  ear  with  the 
antrum,  and  of  the  connection  of  this  with  the  air  cells  of  the  mastoid 
process.  If  the  pus  does  not  succeed  in  running  off  through  the 
perforated  drum,  it  forces  its  way  into  the  neighboring  spaces  and 
from  here  by  two  directions  into  the  temporal  bone.  The  less  danger- 
ous outlet  is  the  formation  of  a  subperiosteal  abscess  under  the  skin 
behind  the  ear,  after  carious  destruction  of  the  mastoid  process.  Far 
more  threatening  for  the  patient  is  the  invasion  of  the  pus  into  deep- 
lying  portions  of  the  temporal  bone,  the  sigmoid  sinus,  the  dura  mater 
and  the  brain. 

^Vhen  the  infection  goes  over  from  the  middle  ear  to  the  mastoid 
cells,  the  symptoms  of  otitis  media  pm'ulenta  are  apt  to  subside  with 
the  appearance  of  symptoms  of  inflammation  of  the  mastoid.  In 
addition  to  fever  and  headache,  which  accompany  the  pain  in  the  ear, 
indefinite  swelling,  reddening  and  imusual  tenderness  to  pressure  in 
the  region  of  the  skin  lying  behind  the  ear  indicate  the  local  process. 
In  children  all  subjective  symptoms,  particularly  spontaneous  pain, 
may  be  wanting  completely,  and  only  jialj^ation  of  the  mastoid  cause 
the  sensation  of  pain.  Also  in  mastoiditis  as  a  residt  of  the  sub- 
cutaneous edema  the  shell  of  the  ear  projects  at  times  from  the  side 
of  the  head.  IMoreover,  for  the  same  reason,  the  upper  wall  of  the 
external  auditory  canal  may  be  depressed  and  the  canal  be  partiallj' 
closed. 

OPENING  UP  THE  MASTOID  CELLS 

The  rapidity  with  which  purulent  infections  pass  over  from  the 
middle  ear  to  the  mastoid  and  cause  sujjpuration  in  the  mastoid  cells 
does  not  always  correspond  to  the  grade  of  severity.  We  see  in 
children  and  sometimes  in  adults  how,  after  an  existing  low-grade 


168  SURGERY  OF  THE  EAR 

otitis  media  or  following  close  upon  an  attack  of  influenza,  a  breaking 
down  of  the  cells  of  the  mastoid  process  occurs.  After  incision  of  the 
overlying  skin  and  a  simple  opening  up  of  the  mastoid  cells  the  stormy 
advance  of  the  process  is  immediately  stopped.  In  children  par- 
ticularly there  may  residt  complete  necrosis  of  the  small  mastoid 
process,  which,  after  being  chiseled  open,  may  be  sponged  away  like 
pulp. 

In  order  to  allow  free  exit  for  the  pus  and  to  prevent  the  least 
retention  under  the  protecting  soft  parts,  the  usual  incision  is  made 
I/O  cm.  behind  the  shell  of  the  ear  and  parallel  to  its  attachment  and 
surrounds  the  mastoid  process  in  a  crescent  which  is  convex  forward 
(Fig.  193,  Plate  35) .  After  dividing  skin  and  periosteum,  the  strong 
cortex  of  the  process  is  chiseled  through  in  a  tangental  direction  from 
before  backward  with  a  bayonet  chisel  (Fig.  194,  Plate  3.5),  and  in 
that  way  a  skin-periosteum-bone  flap  is  lifted  up  which  exposes  the 
cells  of  the  mastoid.  After  cleaning  out  carious  masses,  a  drain  is 
laid  in  the  cavity,  whereupon  the  flap  with  the  thin  shell  of  bone 
attached  is  replaced.  Since  the  nutritional  bridge  is  wide,  it  may  lie 
for  some  time  upon  the  tampon  without  danger  of  necrosis  of  the 
bony  shell.  Even  if  the  bone  dries  at  the  edges,  after  a  week  or  two, 
when  the  secondary  suture  is  undertaken,  there  always  remains  a 
sufficientlj"  large  piece  to  cover  in  by  bony  growth  the  deep  and  ex- 
tensive wound  and  induce  earlier  healing  than  after  any  other 
procedure. 

From  the  circumference  of  the  wound  radiating  incisions  may  be 
made  in  the  soft  parts  of  the  head  or  neck  if  subperiosteal  abscesses 
have  developed  in  the  temporal  or  occipital  region.  If  pus  breaks 
through  at  the  tip  of  the  mastoid  there  results  a  deep  cellulitis  between 
the  neck  muscles.  This  may  be  opened  also  by  an  incision  which  runs 
into  the  operative  incision. 

OPENING  UP  THE  INIASTOID  ANTRUM 

The  simple  operation  just  described  does  not  suffice  if  the  suppin-a- 
tion,  in  acute  purulent  mastoiditis,  instead  of  tending  to  perforate 
the  hard  circimiferential  layer  of  the  mastoid,  progresses  into  the 
deeper  cells.  Then,  in  addition  to  opening  up  the  mastoid  cells,  the 
mastoid  antrum  must  be  laid  open  in  order  to  reach  the  seat  of  infec- 
tion.   The  following  case  may  serve  as  an  example  of  this  procedure: 

A  thirty-two-year-old  cook  was  seized  with  severe  pains  in  the  ear 
and  head.    She  was  rather  confused,  but  was  able  to  tell  that  for  about 


Krause-Heymann-Ehrenfried. 


Tab.  35. 


Exposure  of  the  mastoid  cells. 


Tip  of  mastoid  process 

?'w.  103.  Skill  incision. 


C/iisrl 


Flap  of  skiii-pcnosfaim-boiie 

Fig.  194.  Chiseling  open  the  cortical  bone. 


binan  Company,  New  York. 


Kratise-Hevmann-Eliren  fried. 


Tab.  36. 


Exposure  of  the  tympanic  antrum. 


lnci<.ior 


Fig.  196.  Skin  incision. 


Posterior  wall  of  external  meatus 


Posterior  wall  of  external  meatus 


Linea 

temporalis 


Projection  of  canal  for  facial  nerve 

Fig.  197.  Chiseling  a\x'ay  the  cortical  bone.  Fig.  193.  Exposure  of  the  antrum. 


Rebman  Company,  New  York. 


MASTOID  ANTRUM  169 

three  Aveeks  she  had  been  under  treatment  for  purulent  middle  ear 
disease  and  that  the  drum  liad  been  incised  twice.  After  the  first 
incision  the  symptoms  had  decreased,  but  the  result  was  not  per- 
manent. Her  physician  sent  her  to  the  hospital  because  the  tempera- 
ture had  risen  to  102.2  F.  in  the  evening  and  dizziness  and  nausea  had 
been  present  for  the  past  twenty-four  hours. 

On  examination  it  was  found  that  the  right  external  meatus  was 
much  narrowed  as  a  result  of  swelling  of  the  walls.  The  attempt  to 
introduce  a  speculum  caused  acute  pain.  Through  a  small  incision 
there  came  a  little  foul-smelling  purulent  secretion.  Palpation  of 
the  mastoid  and.  to  a  greater  degree,  tapping  with  the  percussion 
hammer,  particularly  in  the  region  of  the  tip,  caused  severe  pain. 
Pressure  with  the  finger  caused  pitting  of  the  swollen  skin  beliind 
the  ear.  On  account  of  the  poor  general  condition  and  the  local  find- 
ings it  was  decided  that  immediate  opening  up  of  the  mastoid  cells 
and  of  the  mastoid  antrimi  was  necessary. 

The  operation  was  carried  out  in  the  half-sitting  posture.  At  the 
beginning  of  anesthesia  it  was  determined  with  a  small  speculum  that 
the  drimi  was  practically  completely  destroyed  and  in  its  place  was 
a  pasty,  brownish,  purulent  mass. 

A  half  centimeter  behind  and  parallel  to  the  line  of  origin  of  the 
am'icle  an  incision  was  made  concave  forwards  7  cm.  in  length 
(Fig.  196,  Plate  36).  The  spurting  vessels  ceased  to  bleed  as  the 
skin  edges  were  drawn  apart  with  sharji  hooks.  Pus  welled  up  imme- 
diately in  considerable  quantity  in  the  upper  corner  of  the  incision 
from  the  temporal  bone.  Thereupon  the  incision  was  prolonged 
upward  so  that  the  subperiosteal  abscess  could  be  freely  drained. 
The  cortical  layer  of  the  mastoid  process  was  removed  at  once 
with  a  chisel  (Fig.  197,  Plate  36),  so  that  the  diploe  and  tlie  mastoid 
cells  were  exposed.  In  the  direction  of  the  tip  of  the  mastoid  small 
areas  of  suppuration  were  found  in  the  air  cells.  The  necrosed  and 
softened  partition  walls  were  i-emovcd  with  tlie  curette,  and  with  a 
gouge  a  smooth-walled  bony  cavity  was  created.  The  posterior  wall 
of  the  ])ony  auditory  canal  remained  intact  in  its  entire  extent 
(Fig.  198,  I'late  36).  As  drops  of  pus  kept  appearing  in  the  depths 
of  the  bony  fuimel  thus  created,  and  further  necrosis  was  evident, 
opening  up  of  the  mastoid  antrum  was  indicated. 

To  reach  this  the  cavity  was  deepened  further  by  liglit  blows  of 
the  gouge.  All  the  strokes  of  tlie  gouge  were  made  within  a  triangle 
formed  by  lines  joining  the  suprameatal  spine,  the  tubei'cle  of  the 


170 


SURGERY  OF  THE  EAR 


supraniastoid  crest  and  the  tip  of  the  mastoid  process  (Fig.  195). 
The  edge  of  the  chisel  was  always  directed  inwards,  upwards  and 
forwards.  The  chiseling  had  to  be  carried  out  very  carefully,  since 
blood  continually  welled  up  from  the  broken-down  bony  partitions, 
and  as  a  result  the  view  in  the  apex  of  the  funnel-shaped  opening  was 
rendered  difficult.  From  time  to  time  an  attempt  was  made  through 
pressure  with  small  sponges  about  the  size  of  a  bean,  saturated  with 
a  solution  of  suprarenin,  to  control  the  bleeding. 


Fig.  195 
Area  of  cortical  bone  chiseled  away  in  exposure  of  the  t3'mpanic  antrum. 


At  the  depth  of  over  3  cm.  the  funnel-shaped  wound  in  the  bone 
finally  passed  over  into  a  large  cavity,  which  by  its  location  corre- 
sponded to  the  mastoid  antrum.  After  cleaning  out  the  slimy,  tena- 
cious pus  and  breaking  away  the  ring-shaped  entrance  into  this  cavity, 
two  bony  eminences  were  to  be  seen,  on  the  floor  anteriorly,  of  which 
the  anterior  and  lower  corresponded  to  the  projection  over  the  facial 
nerve,  and  the  rather  more  definitely  projecting  upper  prominence 


Krause-Heymann-Ehrenfried  Tab.  37. 

Radical   operation   in  chronic  purulent  middle  ear  disease. 


Opening  for 
exposure  of 
the  antrum 


Boundary  of  ^ 
opening  for  the  a 
radical  operation     '  ^ 


Elevator 


Posterior  wall 
of  bony  external 
uudit'orv  canal 


Fig.  199.  Area  of  cortical  bone  to  be  chiseled  away. 


Fig.  200.   Prying  off  the  skin  lining  the  bony 
auditorv  canal. 


Posterior  wall  of  ex- 
ternal auditory  canal 


"l^"- 


Fig.  201.  The  facial  nerve  is  avoided 

Antrum,   and  approach  to  the  attic 


External  semicircular  canal 


Lateral  sinus 


Projection  of  canal  for  facial 

nerve,  in  remnant  of  posterio) 

wall  of  auditory  canal 


Fig.  202.  Chiseling  away  posterior  wall  of  bony 
external  auditory  canal. 


Skin  of  external  auditory  canal 


Middle  ear 

Fig.  203.   Wound  cavity  after  radical   operation. 


Rebinan  Company,  New  York. 


RADICAL  MASTOID  OPERATION  171 

corresponded  to  the  prominence  of  the  lateral  semicircular  canal 
(Fi^".  li>8.  I'late  36). 

Anterior  and  external  there  still  remained  a  sharply  projecting 
process,  which  hindered  the  view  of  the  passage  from  the  antrum  to  the 
middle  ear.  ^Vith  a  very  small  chisel  this  projection,  which  by  its  posi- 
tion corresponded  with  the  bony  frame  of  the  posterior  edge  of  the 
drum,  was  chiseled  an-ay.  Below,  this  prominence  passed  over  into  the 
eminence  of  the  canal  of  the  facial  nerve.  As  this  was  removed,  it 
could  be  seen  that  the  contents  of  the  middle  ear  had  been  transformed 
into  a  completely  unrecognizable  greasy  mass.  The  attempt  to  find 
the  remnants  of  the  ossicles  in  this  mixture  of  pus,  mucus  and  necrotic 
tissue  was  unsuccessful. 

In  consideration  of  the  destruction  of  the  contents  of  the  middle 
ear  and  drum,  as  well  as  the  cerebral  symptoms,  which  had  ajjpeared 
after  a  three-weeks'  course  of  the  disease,  it  appeared  necessary  to 
carry  out  the 

RADICAL  OPERATION 

Since  the  purpose  of  this  operation  is  to  transform  the  external  audi- 
tory canal,  the  middle  ear,  the  mastoid  antrum  and  the  inside  of  the 
mastoid  process  into  a  single  wide  wound  cavity,  as  smooth  as  jjossible, 
and  opening  externally,  there  remained  only  the  removal  of  the  jjos- 
terior  wall  of  the  auditory  canal  and  a  complete  opening  up  of  the 
mastoid  process   (Fig.  199,  Plate  37). 

Accordingly  the  forward  edge  of  the  wound,  together  with  the 
auricle,  was  pried  up  from  the  l)ony  canal  with  the  helj)  of  an  elevator 
until  the  skin  lining  of  the  auditory  canal  tore  away  within  (Fig.  200, 
Plate  37).  The  auricle  and  the  portion  of  the  external  canal  which 
was  torn  away  with  it  was  next  drawn  forward,  and  later  in  the  course 
of  the  operation  was  attached  with  a  few  sutures  of  silk  to  the  anterior 
wall  of  the  canal. 

The  bony  ])osterior  wall  of  the  canal  was  removed  with  a  few 
strokes  of  the  chisel,  holding  it  always  directed  ui)ward  and  inward. 
In  order  to  maintain  tlie  direction  of  the  attic  and  not  to  endanger 
the  facial  nerve,  which  ran  under  the  floor  at  the  boundary  of  middle 
ear  and  antrum,  the  teehiuque  of  Stacke  was  followed,  by  which  a  bent 
probe  was  introduced  through  the  antrum  and  middle  ear  into  the 
auditory  canal  (Fig.  201,  Plate  37),  and  on  tliis  the  blows  of  the 
chisel  were  directed  (Fig.  202,  Plate  37).  Further  in,  the  removal 
of  the  posterior  wall  of  the  canal  was  limited  to  the  upper  posterior 


172  SURGERY  OF  THE  EAR 

quadrant,  since  the  facial  nerve  runs  below  in  the  line  of  the  posterior 
wall. 

On  the  otlier  hand,  the  upper  bony  wall  was  removed  freelj'  above 
until  the  communication  with  the  antrum  and  with  the  attic  lay  opened 
up  and  the  probe  could  be  removed.  Below  this  the  prominence  of  the 
facial  nerve  completely  blocked  the  vision,  and  it  was  removed  in  small 
lamellfE  with  a  small.  strai<)fht  chisel,  until  the  anesthetist  rejjorted  that 
there  was  twitching  of  one  side  of  the  face.  Finally  the  strip  of  bone 
on  the  roof  of  the  large  cavity  (Fig.  20.3,  Plate  37)  was  levelled  off, 
partly  with  the  curette  and  partly  with  very  fine  rongein-s.  In  the 
attic,  also,  no  trace  of  the  ossicles  was  to  be  found.  Bleeding  was 
stronger  on  the  floor  of  the  cavity  than  on  the  roof. 

After  all  bony  splinters,  inspissated  pus  and  necrotic  tabs,  as  well 
as  the  remnant  of  the  drum,  were  removed  by  wiping,  the  bony  cavity 
was  packed  with  iodoform  gauze  and'  an  occlusive  dressing  applied. 
The  facial  eminence  was  lightly  sponged  and  carefully  packed  with 
gauze  in  order  to  avoid  injury  to  the  nerve  as  the  result  of  tearing  with 
bony  splinters  or  through-  jjressure  of  sponges. 

On  the  day  after  operation  the  temperature  was  normal.  The 
symptoms  of  septicemia  improved  rapidly.  The  superficial  layer  of 
the  dressing  was  changed  in  two  days  and  the  gauze  packing  in  the 
cavitv  four  davs  later.  From  that  time  on  the  dressing  was  com- 
pletely  changed  every  third  day.  The  entire  wound  covered  in  rapidly 
with  vascular  gramdations.  The  secretion  of  pus  ceased.  Two  weeks 
after  operation  the  patient  left  the  bed.  and  soon  the  cavity,  which 
was  the  size  of  the  end  of  the  thumb,  began  to  dermatize  rapidly  from 
the  edges.  The  sutures  which  held  the  jiosterior  skin  wall  of  the 
auditory  canal  to  the  anterior  gradually  cut  through.  The  periosteum 
and  skin  of  the  auricle  healed  to  the  anterior  wall  in  the  following 
weeks,  so  that  from  here  also  dermatization  of  the  canal  spread. 

THE  PLASTIC  PROCEDURE  OF  PANSE-KORNER 

When  practically  the  entire  wound  surface  was  scarred  over,  the 
picture  in  Fig.  204,  Plate  38,  presented  itself.  As  not  infrequently 
happens  after  opening  up  the  antrum,  and  always  after  the  radical 
operation,  it  was  necessary  to  transform  tlie  bony  funnel  which  lay 
open  behind  the  ear  by  means  of  a  plastic  operation  into  an  auditory 
canal  protected  by  the  external  ear.  For  this  purpose  the  Panse- 
Korner  method  was  chosen. 

First  the  dermatized  edges  of  the  funnel  were  trimmed  in  the  form 


Krause-Heymanii-Ehrcnfried.  -t-_[j    -jg 

Railical   nuistoid:  the  Panse-Korner  method  of  plastic  closure. 


Bony  cavity 
lined  with  skin 

Remains  of 
external  audi- 
tory canal 
grown  together 

Line 
of  incision 


Fig.  204.  Bony  cavity  lined  with  scartissue. 


Cartilage 


Lower  accessory  incision 

Fig.  205.  Freeing  up  the  concha. 


Ciiinze  strip 
in  upper 
accessory 
incision 

Concha 
after  remo- 
val of 
portion  of 
cartilage 


Fig.  206.  Freeing  up  the  cartilage. 


Fig.  207.  First  sutures  applied. 


Lower  accessory 
incision 


Fig.  208.  Sewing  concha  to  posterior 
wound  margin. 


rl 


,-i- 


r 


•  4 


^      Suture  tinf 


h'ig.  209.  Completion  of  suture. 


Rebmann  Company,  New  Vork. 


THE  PANSE-KORNER  PLASTIC  173 

of  an  ellipse,  and  at  the  posterior  circumference  of  the  wound  the 
soft  parts  were  loosened  up  from  the  skull.  In  front  the  posterior 
wall  of  the  canal,  wliich  had  l)ecome  adherent,  was  freed  up  in  all  of  its 
three  layers  from  the  anterior  wall,  so  that  a  pair  of  forceps  intro- 
duced into  the  meatus  was  seen  in  the  cavity  (Fig.  20.5,  Plate  38). 
^Vhile  the  posterior  wall  of  the  skin  of  the  canal  was  hfted  from  the 
skull,  an  oblitjue  incision  was  made  through  all  the  layers  of  the 
external  ear  above  and  below,  starting  from  the  freshened  edges. 
Both  incisions  ran  close  to  the  helix  above  and  below  in  order  to  give 
plenty  of  material  for  covering  the  wide  bony  cavit}\  Since  in  the 
flap  thus  formed  movement  was  limited  to  a  high  degree  by  the  plate 
of  cartilage,  this  was  seized  with  forceps  (Fig.  206,  Plate  38),  over 
1  cm.  was  exposed  and  removed  with  scissors.  This  allowed  the  base 
of  the  flap  to  be  drawn  easily  and  without  tension  over  to  the  posterior 
wall  by  means  of  a  loop  of  gauze  introduced  in  the  upper  accessory 
incision,  and  there  to  be  made  fast  with  four  interrupted  sutin-es 
(Fig.  207.  Plate  38).  In  the  same  way  the  rest  of  the  mobilized 
woinid  edges  were  sewed  together  (Fig.  208,  Plate  38)  until  the 
entire  bony  cavity  was  covered  with  the  shell  of  the  ear  (Fig.  209, 
Plate  38).  Below  the  obliquely  placed  accessory  incision  was  satis- 
factorily employed  for  uniting  the  Avound  edges,  while  the  upper  one 
was  sewed  together  partially  in  a  horizontal  line.  Finally,  in  the 
external  ear,  wliich  led  directly  into  the  large  bony  funnel,  a  strip  of 
vioform  gauze  was  introduced. 

Two  weeks  later  the  patient  was  discharged  healed.  The  bony 
cavity  which  resulted  from  the  radical  operation  had  to  be  packed  for 
a  considerable  time,  later  through  the  canal  with  strips  of  gauze. 

In  opening  up  the  mastoid  antrum  particular  difficulties  are  pre- 
sented if  the  mastoid  process  is  converted  into  a  compact  mass  of  bone 
without  means  of  difl'erentiation  between  the  cortical  and  the  spongy 
portions.  This  ehurnlzalion  is  the  result  of  chronic  inflammation,  and 
in  chiseling  open  such  a  mastoid  neither  the  narrow  space,  rich  in 
blood,  nor  the  white-lined  pneumatic  cells  are  to  be  recognized;  and 
as  a  result  all  points  of  departiu'e  for  the  recognition  of  the  facial 
eminence,  the  sigmoid  sinus,  the  cranial  cavity  and  of  the  antrum 
in  chiseling  are  lost.  Also  more  force  must  be  given  to  the  blows 
of  the  chisel  than  are  necessary  in  the  cellular  bone. 

The  passage  to  the  dark  antrum  may  lie  high  up  under  and  even  above 
the  supramastoid  crest,  and  its  cavity  may  be  so  narrow  that  from 


174  SURGERY  OF  THE  EAR 

this  point  neither  the  facial  eminence  nor  the  prominence  of  the  lateral 
semicircular  canal  is  to  be  differentiated.  It  is  better  in  such  cases  to 
make  the  bonj'  funnel  too  high  rather  than  too  close  to  the  tip  of  the 
mastoid  jjrocess,  as  opening  the  middle  fossa  presents  a  less  danger 
than  injury  of  the  facial  nerve  in  the  posterior  wall  of  the  middle  ear, 
and  at  the  floor  of  the  antrum. 

In  the  radical  operation  the  facial  nerve  is  in  particular  danger 
■while  the  posterior  wall  of  the  external  canal  is  being  removed.  Even 
if  the  probe  or  the  facial  protector  of  Stacke  is  introduced  from  the 
antrum  to  the  bony  meatus,  and  all  the  blows  of  the  chisel  are  directed 
to  these  instruments,  the  facial  may  be  injured  through  a  fissure 
made  in  chiseling,  by  a  bony  splinter  or  by  pressure  of  the  forceps 
which  hold  the  sponge.  It  is  chiefly  endangered  in  its  passage  from 
the  posterior  wall  of  the  canal  over  to  the  medial  wall  of  the  middle  ear. 

The  sigmoid  sinus  sometimes  deviates  from  its  customary  position. 
While  as  a  rule  it  runs  along  the  posterior  edge  of  the  mastoid  process, 
it  may  be  placed  so  far  to  the  front  in  the  bony  mass  of  the  mastoid 
as  to  lie  anterior  to  the  middle  line  of  the  mastoid,  in  which  case  it 
may  readily  be  injured  in  chiseling.  If  this  occurs,  pressure  and  pack- 
ing with  a  small  strip  suffice  to  overcome  the  bleeding  from  its  injured 
Avail.     The  operative  procedure  need  not  be  interrupted. 

PHLEBITIS  AND  THROMBOSIS  OF  THE  SIGMOID  SINUS  AND 
LIGATURE  OF  THE  JUGULAR  VEIN 

Abscesses  in  the  mastoid  process  always  endanger  the  neighboring 
large  vessels.  The  infection  travels  from  the  mastoid  cells  to  the  sig- 
moid sinus  and  to  the  gulf  of  the  internal  jugular  vein  from  the  floor 
of  the  middle  ear.  Either  there  results  a  purulent  jihlebitis  of  the 
wall  of  the  sinus  or  the  formation  of  a  septic  thrombus.  The  throm- 
bosis in  the  majority  of  cases  remains  stationary  and  only  seldom  fills 
the  lumen  of  the  sinus  completely. 

In  purulent  inflammation  of  the  walls  of  the  sinus  first  the  stream 
of  blood  is  interrupted  within  the  vessel.  Externally  the  participation 
of  the  wall  is  recognized  by  the  fact  that  it  is  covered  with  a  smeaiy, 
yellowish  layer.  The  passage  of  pus  organisms  through  the  wall  of 
the  vessel  may  follow  readily  in  this  stage  and  lead  to  the  symptoms 
of  pyemia. 

The  symptoms  of  parietal  and  obstructing  thrombosis  of  the 
sinus  are  at  first  indefinite  so  long  as  the  clot  is  limited  to  only  a  short 
stretch  of  the  sinus  and  it  sticks  fast  to  the  wall.     Onlv  when  the 


PHLEBITIS  AM)  TIIROMHOSIS  OF  THE  SIGMOID  SINUS     175 

thrombosis  progresses  to  blood  vessels  in  the  immediate  neighborhood 
or  further  removed  and  if  infected  portions  of  tlie  weakened  thrombus 
are  torn  loose  does  general  pyemia,  wliieh  is  usually  fatal,  occur. 

Therefore,  among  the  symptoms  of  septic  sinus  thrombosis  the 
sjTiiptonis  of  ])yeniia  stand  first.  The  obstruction  to  tlic  passage  of 
blood  expresses  itself  in  the  tilled  appearance  of  the  veins  of  the  face 
and  head,  in  swelling  of  the  skin  of  the  face,  particularly  the  eyelids, 
and  further  in  paralysis  of  the  cranial  nerves,  which  lie  close  to  the 
thrombosed  vessels  or  in  the  sinus  cavernosas.  These  symptoms  only 
exceptionally  appear  sinniltaneously,  since  they  depend  on  the  extent 
of  the  throml)osis:  but  for  diagnosis  and  as  an  indication  for  opera- 
tion a  single  isolated  symptom,  such  as  edema  of  the  lids,  an  isolated 
nerve  paralysis,  or  a  filled  vein,  or  in  connection  with  the  findings 
in  the  ear  and  the  symptoms  of  general  pyemia,  may  be  a  valuable 
index. 

In  the  further  course  of  the  disease  one  other  very  characteristic 
symj)tom  rarely  fails.  As  the  result  of  the  advance  of  phlebitis  of 
the  sinus  to  the  jugular  vein  there  occurs  a  definite  tenderness  along 
the  vein.  The  point  of  greatest  tenderness  is  at  the  posterior  edge 
of  the  mastoid  process,  and  it  extends  sometimes  as  far  as  the  clavicle. 
The  occiput  is  usually  held  immovably  upon  the  shoulder  of  the 
affected  side  and  the  face  is  turned  to  the  opposite  side.  The  ede- 
matous swelling  behind  and  under  the  mastoid  process,  as  well  as  over 
the  upper  portion  of  the  jugular  vein,  may  show  externally  the  pres- 
ence of  phlebitis;  it  may  be  definite  or  it  may  not  be  present  at  all, 
since  the  deep  fascia  of  the  neck  and  the  sterno-mastoid  muscle  cover 
the  inflamed  and  infiltrated  tissue. 

A  healthy  nineteen-year-old  workman  was  admitted  to  the  surgical 
section  of  the  Augusta  Hospital  in  a  state  of  coma.  Since  he  himself 
could  give  no  information,  but  little  could  be  learned  concerning  his 
previous  history.  For  several  weeks  he  had  complained  of  pain  in 
the  ears,  and  the  past  few  days  he  had  frequently  vomited  in  the 
morning,  but  he  had  nevertheless  kept  at  his  work  until  three  days 
preceding  entrance.  On  account  of  dizziness  and  severe  headache  in 
the  morning  he  could  no  longer  get  up.  Since  then  fever  and  chills 
lasting  more  than  half  an  horn-  had  been  observed,  and  finally  he  had 
been  sent  to  the  hospital  by  his  physician. 

It  was  found  that  the  right  side  of  the  neck  from  the  mastoid  process 
to  the  middle  of  the  sterno-mastoid  was  markedly  swollen.  Kvcry 
attempt  to  palpate  this  area  for  diagnostic  purposes  was  responded  to 


176  SURGERY  OF  THE  EAR 

by  the  patient,  otherwise  in  a  state  of  somnolence,  Avitli  active  expres- 
sions of  pahi.  There  existed  further  pauiful  swelHng  in  the  left  elbow 
joint  and  enlargement  of  the  liver  and  spleen;  the  temperature  was 
104  F.  and  the  pulse  rate  140  per  minute.  No  dilatation  of  the  veins 
of  the  skin  of  the  neck  was  visible,  but  there  was  tortuosity  and  injec- 
tion of  the  veins  of  the  right  retina.  The  right  side  of  the  face  moved 
less  than  the  left. 

Examination  of  the  left  ear  showed  nothing  abnormal.  On  the  right 
side  the  external  auditory  canal  was  filled  with  a  brown,  pasty  secre- 
tion, the  drum  showed  a  circular  hole  exactly  in  the  middle,  its  upper 
edge  was  covered  with  pus  and  the  lower  was  markedly  swollen  and 
hemorrhagic.  Nothing  was  to  be  seen  of  the  ossicles,  but  the  white 
light-reflecting  surface  of  the  medial  wall  of  the  middle  ear  could  be 
seen.  On  account  of  the  condition  of  the  patient  paralysis  of  the 
muscles  of  the  eye  could  not  be  determined. 

On  consideration  of  these  symptoms  the  diagnosis  appeared  clear. 
Starting  from  an  old  pinnilent  otitis  media,  there  had  developed  a 
purulent  phlebitis  of  the  sigmoid  sinus  and  the  jugular  vein,  which,  in 
addition  to  a  local  infection  of  the  right  side  of  the  neck,  had  resulted 
in  a  general  pyemia.  In  order  to  prevent  further  progress  of  the 
pyemia  so  far  as  possible  in  a  patient  whose  life  appeared  to  be  in 
the  gravest  danger,  it  was  decided  that  the  sigmoid  sinus  should  be 
exposed  and  the  jugular  vein  ligated. 

Under  light  ether  anesthesia  the  skin  and  periosteum  over  the 
mastoid  process  were  divided  !/>  cm.  behind  and  parallel  to  the  furrow 
of  the  concha,  and  drawn  apart  with  retractors.  Departing  from  the 
customary  procedure  in  opening  up  the  antrum,  the  mastoid  process 
was  opened  wide  and  further  back  than  usual,  and  direct  approach 
was  made  to  the  sigmoid  sinus.  The  use  of  the  hammer  and  chisel 
was  avoided  because  of  the  danger  that  with  each  jar  new  pieces  of 
septic  clot  would  be  set  loose  in  the  vein.  For  that  reason  trephining 
of  the  mastoid  was  carried  out  with  the  burr  (for  the  technique  see 
chapter  on  Surgery  of  the  Brain),  and  the  bone  was  broken  out  from 
the  edge  of  the  drill  hole  Avith  rongeurs. 

The  exposed  sinus  was  yellow  and  covered  with  fibrin  and  pus. 
This  layer  could  be  removed  with  forceps.  Also  imder  it  the  wall  of 
the  sinus  was  discolored,  but  blood  must  have  flowed  in  its  lumen,  since 
it 'filled  and  emptied  itself  regularly  with  respiration.  To  be  sure  it 
was  not  under  normal  tension,  but  on  careful  palpation  nowhere  could 


Krause-Heyniann-Ehrenfiicd. 

'll-irombophlcbitis  of  the   lateral   sinus,   and   lis^ature 
of  the  internal  jugular  \ein. 


FibrinO'iiiinilfiit  layer 
Knee  of  sinus 


Piini  iiititrr  of 
the  cerebeUum 


Tab.  39. 


Squamous  portion 
of  oidpital  boat' 


l.ynipli  node 


Lymph  nodi 


Fig.  210.  Exposure  of  the  lateral  sinus  and 
the  great  vessels  of  the  neck. 


Double  ) 
ligature  \ 


Krsrcteil  /witiiw  of  jiigiilur  vrin 


^       Ciirotid  iitlfry 
Vagus  ut'i-ve 


Fig.  211.  Ligation  of  the 

jugular  vein  and  its 

branches. 


Fig.  212.  Resection  of  jugular  vein. 


Rrbiiian  Company,  Nevi   N'mk. 


LIGATION  OF  THE  JUGULAR  AEIN  177 

thrombi  be  felt.  Also  the  sinus  could  apparently  be  emptied  in  both 
directions. 

Further  exposure  of  the  sigmoid  sinus,  or  even  of  the  gulf  of  the 
jugular  vein,  as  well  as  any  radical  operation,  had  to  be  given  up  on 
account  of  the  bad  condition  of  the  patient,  lint  in  order  at  least  to 
remove  the  source  of  the  pyemic  infection,  in  addition  to  the  exposure 
of  the  sinus,  the  common  jugular  vein  had  to  be  ligated. 

For  this  purpose  the  incision  behind  the  ear  was  lengthened  down- 
wards over  the  anterior  border  of  the  sterno-mastoid  to  near  the 
clavicle.  The  fascia  of  the  nuiscle  was  split  at  its  anterior  edge  and 
the  sheath  containing  the  blood  vessels  and  lymph  glands  was  opened. 
As  the  muscle  was  drawn  backward  there  came  into  sight  swollen 
lymph  nodes  as  long  as  the  phalanx  of  the  finger,  embedded  in 
brawny  edema  (Fig.  210,  Plate  39).  These  were  the  cause  of  the 
painful  infiltration  of  the  neck.  After  splitting  the  sheath,  it  was 
seized  with  forceps  and  removed,  the  internal  jugular  vein  was  ex- 
jjosed,  double  tied  and  divided  in  the  lower  end  of  the  wound  (Fig. 
211,  Plate  39) .  The  common  facial  vein  and  a  series  of  small  branches 
were  divided  after  double  ligature  and  a  piece  of  the  internal  jugular 
vein  6  cm.  long  (Fig.  212,  Plate  39)  was  resected.  The  exposed  sur- 
face of  the  dura  and  the  wound  over  the  vessels  was  packed  with  iodo- 
form gauze  and  the  edges  of  the  skin  were  loosely  united  over  the 
gauze  by  three  sutures. 

In  spite  of  the  short  and  very  superficial  ether  anesthesia,  the  patient 
collapsed  at  the  end  of  operation.  After  the  operation  no  more  chills 
ajjpeared,  and  the  fever  remained  moderate.  On  account  of  the  in- 
crease in  pulse  rate  and  persisting  disturbance  of  consciousness,  the 
prognosis,  however,  appeared  hopeless.  On  the  second  day  after 
operation  the  patient  died. 

From  the  autopsy  protocol  (Professor  Ostreich)  it  appears  that 
a  purulent  thrombosis  was  found  in  the  right  transverse  sinus.  The 
wall  of  the  vessel  was  three  times  as  thick  as  normal,  was  discolored 
and  infiltrated  with  pus.  The  brain  substance  was  injected,  but  with- 
out foci.  The  wall  of  the  jugular  vein  was  thickened.  Below  the 
point  of  ligation  in  the  neck  the  large  veins  were  free  of  thrombi. 
There  were  present  also  septic  infarcts  in  the  lungs,  fibrinous  deposits 
in  the  pleura,  softening  of  the  cardiac  muscle  and  septic  enlargement 
of  the  spleen,  as  well  as  fatty  degeneration  of  the  liver  and  kidneys. 

If  the  patient  had  come  to  operation  in  better  condition,  radical 


178  SURGERY  OF  THE  EAR 

operation  on  the  ear  and  exposure  of  the  transverse  sinus  would 
necessarily  have  followed  trephining  of  the  mastoid  and  ligatiu'e  of  the 
internal  jugular  vein.  If  one  finds  in  a  similar  case  that  the  sinus  is 
plugged  by  infected  thrombi,  its  walls  should  be  opened  and  the 
thrombus  removed.  Bleeding  from  the  sinus  after  opening  may 
easily  be  controlled  by  introducing  a  narrow  strip  of  gauze,  impreg- 
nated with  iodoform  on  account  of  the  sepsis,  and  allowing  it  to  re- 
main for  about  seven  days.  After  this  time  innocuous  clot  formation 
is  apt  to  put  a  stop  to  further  bleeding. 

The  complication  of  pmndent  middle  ear  disease  with  disease  of 
the  brain  and  its  envelopes  will  be  considered  in  a  special  section. 


CHAPTER    11— SURGERY    OF   THE   NOSE   AND    THE 
ACCESSORY  SINUSES 

INJURIES  OF  THE   NOSE 

may  be  danfrerous  if  combined  with  profuse  bleeding  from  the  mucous 
membrane  or  if  wound  infection  occurs  in  the  tortuous  nasal  passages. 
I'ractically  all  fractures  of  the  nasal  bones  result  from  direct  violence 
and  the  majority  are  complicated  with  wounds  of  the  nnicous  mem- 
brane lim'ng.  In  every  case  of  fracture  of  the  nose,  in  addition  to  the 
control  of  hemorrhage  and  prevention  of  infection,  the  threatened 
facial  disfigurement  above  all  things  demands  surgical  intervention. 

Usually  sim])le  packing  of  the  nasal  cavity  with  iodoform  gauze 
suffices  to  stop  bleeding,  and  infection  in  comjjound  fractures  is  best 
guarded  against  by  such  procedure.  In  order  not  to  completely 
obstruct  nasal  breathing  after  packing  of  the  nasal  cavity  with  gauze, 
a  small  but  stiff-walled  rubber  tube  should  be  introduced  at  the  same 
time  as  far  as  the  naso-pharynx. 

Iodoform  gauze  is  to  be  recommended  for  this  purpose  over  plain 
sterile  gauze  because  it  may  remain  in  place  for  several  days  without 
decomposition  taking  place.  The  gauze  should  always  be  used  in  the 
form  of  ta})c.  for  a  packing  composed  of  several  tapes  may  be  removed 
much  more  readily  than  a  single  strip.  The  packing  should,  however, 
not  be  allowed  to  stay  in  too  long,  as  we  have  seen  meningitis  develop 
four  days  after  an  apparently  mild  injur}"  for  which  the  nose  was 
packed,  and  on  withdrawing  the  packing  free  pus  followed,  Avhich 
apparently  had  been  retained  under  pressiu'e.  Auto|)sy  showed  a 
fissure  fracture  of  the  etlinioid. 

Markedly  dislocated  fragments  which  projected  freely  into  the 
nasal  cavity  should  be  removed  at  once,  for  they  often  become  necrotic, 
and  if  they  are  allowed  to  come  away  of  themselves  as  sequestra  the 
process  is  slow  and  often  accom])am'ed  by  disturbing  syniptonis  of 
inflammation  in  the  anterior  ])()rtion  of  the  nose. 

Cracks  in  the  bony  wall  and  fresh  (Irviations  of  the  ficpium  as  a 
result  of  injuries  are  corrected  at  once  by  packing.  For  the  hematoma 
which  results  from  fractures,  and  at  times  also  the  subcutaneous  em- 
physema, immediately  renders  dillieult  the  view  within  tiie  nose. 
^^'hile  at  first  the  displaced  fragments  may  be  replaced  readily,  later 

179 


180  SURGERY  OF  THE  NOSE  AND  SINUSES 

on  this  is  impossible.  Accordingly,  many  nasal  fractures  heal  with 
permanent  disfigurement.  Improvement  can  then  be  offered  by  sub- 
cutaneous osteotomy  Avith  the  help  of  fat  or  bone  transplantation,  as 
has  been  shown  hi  the  section  on  plastics  of  the  cheek  and  nose 
(see  pp.  105  and  139). 

Spontaneous  bleeding  from  the  nose  results  from  small  ectactic 
veins,  and  less  frequently  arteries,  which  are  situated  in  the  lower 
anterior  section  of  the  mucous  membrane  of  the  septum,  the  so-called 
Kesselbach's  spot. 

In  order  to  stojD  the  bleeding  it  usually  suffices  to  press  the  alte  of 
the  nose  together  for  several  minutes  between  thumb  and  forefinger. 
If  this  does  not  control  it  the  nasal  cavity  shoidd  be  packed  from  in 
front  with  gauze,  which  may  be  saturated  with  a  mild  solution  of 
suprarenin.  If-  this  treatment  does  not  succeed,  the  nose  must  be 
packed  from  behind,  particularly  if  the  blood,  without  appearing  in 
the  nasal  orifices,  runs  down  the  wall  of  the  jjliarynx.  The  packing 
is  inserted  through  the  mouth  into  the  naso-pliarynx  by  means  of  a 
Bellocque  cannula,  or  better  still,  a  soft  rubber  catheter.  The  catheter 
is  passed  along  the  floor  of  the  nose  until  its  end  appears  projecting 
below  the  soft  palate,  when  it  is  seized,  brought  forward  through  the 
mouth  and  the  gauze  strip  is  attached  to  it  by  a  string  of  silk  and 
drawn  back  into  the  naso-pharynx  and  the  posterior  nasal  orifice.  The 
plug  should  be  of  such  size  that  it  will  not  wedge  in  between  the 
velum  and  the  pharyngeal  wall,  but  will  be  drawn  into  the  posterior 
nasal  orifice  and  plug  it  effectively.  The  silk  cord  is  made  fast  to 
the  cheek  with  a  strip  of  adhesive  plaster.  After  the  posterior  pack- 
ing is  applied,  the  anterior  nares  is  packed  so  as  to  completely  fill  the 
nasal  fossa.  Iodoform  gauze  may  remain  in  for  a  week  or  more ;  other 
packing  should  be  changed  earlier,  not  later  than  forty-eight  hours, 
because  it  may  decompose  and  become  a  source  of  danger  to  the 
patient.  Removal  of  the  packing  is  rendered  less  difficult  if  it  is 
previously  softened  thoroughly  by  soaking  with  oil  or  liquid  albolin. 

In  order  to  prevent  return  of  the  epistaxis,  it  is  recommended  to 
cauterize  the  bleeding  point  on  the  septum  or  on  the  turbinate  with 
a  galvano-cautery,  the  Pacquelin  cautery,  or  by  means  of  chemical 
agents,  such  as  silver  nitrate  or  trichloracetic  acid,  and  in  this  way 
induce  scarring  of  the  vessels  w^hicli  are  inclined  to  bleed.  It  is  neces- 
sary to  first  dry  the  bleeding  point  as  thoroughly  as  possible  and  have 
the  cauterant  agent  ready  to  apply  immediately  upon  withdrawal  of 


SINUITIS  181 

the  pressure  sponge.     The  neif^-hboriiig  portions  of  the  nasal  orifice 
should  be  protected  from  burning  by  a  speculum. 

Death  following  epistaxis  is  not  uncommon.  We  have  recently 
seen  two  patients  who  in  spite  of  the  fact  that  the  bleeding  was  con- 
trolled through  j)osterior  and  anterior  packing,  died  a  few  days  after 
admission  to  the  hospital  from  anemia  and  exhaustion. 

INFLAMMATORY  DISEASES  OF  THE  ACCESSORY  SINUSES 

The  source  of  inflammatory  disease  of  the  accessory  sinuses  is  acute 
and  chronic  rhinitis,  which  extends  along  the  mucous  membrane  lining 
the  open  passages  wiiich  lead  from  the  nose  to  the  sinuses.  Of  these, 
the  duct  of  the  frontal  sinus  opens  anteriorly  below  the  middle  turbi- 
nate in  the  hiatus  semilunaris.  Somewhat  posterior  is  the  orifice  of 
a  second  canal  which  leads  to  the  anti'um.  Between  the  two  projects 
the  largest  of  the  anterior  ethmoid  cells,  the  bulla  ethmoidalis.  Both 
cavities  are  easy  to  probe  through  the  middle  meatus  after  some 
practice,  and  to  irrigate  for  therapeutic  purposes  by  means  of  cannulas. 
The  passage  to  the  sphenoid  cells  is  more  difficult  to  reach;  it  opens 
in  common  with  the  posterior  cells  of  the  ethmoid  in  the  upper  meatus 
below  the  su])erior  turbinate.  The  Eustachian  tube  opens  in  the  naso- 
pharynx at  the  end  of  the  lower  meatus,  connecting  the  naso-pharynx 
with  the  middle  car. 

Simple,  acute  or  chronic  sero-catarrhal  inflammation  of  a  sinus 
may  disappear  like  the  same  affection  in  the  nose  without  permanent 
disturbance;  in  the  same  way  acute  purulent  inflammations  may  often 
be  overcome  without  special  surgical  procedure.  Fever,  dull  pain  in 
the  jaw  and  forehead,  neuralgic  pains  in  the  region  of  the  supra- 
and  infra-orbital  nerves,  as  Avell  as  nasal  speech  and  the  appearance 
of  purulent  secretion,  are  the  principal  symptoms  which  denote  that 
the  sinuses  are  involved.  The  pain  is  apt  to  increase  in  severity  on 
sneezing  and  coughing.  Chronic  inflammation  is  evidenced  also  by 
the  long  course  of  the  disease,  and  particularly  by  fluctuations  in  the 
.symptoms.  Thus  the  symptoms  decrease  if  the  swelling  of  the  mucous 
membrane  in  the  orifice  of  the  canals  diminishes  and  the  pus  is  allowed 
to  drain  away  into  the  nose  or  pharynx.  The  disagreeable  odor  and 
the  taste  of  pus  is  then  found  to  be  very  un])leasant  by  the  patient.  In 
the  interval  asthmatic  conditions  not  unusually  api)car.  Progression 
of  purulent  inflamuiation  to  the  orbit,  or  even  to  the  interior  of  the 
skull,  presents  in  acute  as  well  as  chronic  suppuration  of  the  sinuses 
a  dreaded  but  infrequent  complication. 


182  SURGERY  OF  THE  NOSE  AND  SINUSES 

Diagnosis  of  suppuration  of  a  siiuis  is  not  difficult  to  make  if  one 
finds  pus  in  the  middle  meatus  through  the  speculum.  Here  the 
secretion  empties  itself  from  the  frontal  sinus,  the  antrum,  and  from 
the  anterior  cells  of  the  ethmoid.  As  suppuration  of  the  anterior  cells 
of  the  ethmoid  without  the  posterior  is  practically  never  observed,  the 
antrum  and  the  frontal  sinus  are  usually  the  source  of  the  pus.  If  the 
chronic  purulent  inflammation  is  limited  to  the  ethmoid,  in  addition 
to  the  secretion  under  the  middle  meatus  one  will  be  able  to  see  pus 
flow  from  the  upper  meatus  by  means  of  posterior  rhinoscopy. 
Chronic  suppuration  seldom  occurs  here  alone.  As  a  rule  it  is  com- 
bined with  the  same  disease  of  other  cavities.  In  the  same  way  a 
primary  and  isolated  abscess  in  the  antrum  without  involvement  of 
other  sinuses  is  practically  never  observed.  The  presence  of  disease 
of  the  sphenoid  may  be  determined  by  finding  secretion  from  the  pos- 
terior cells  of  the  ethmoid  with  the  aid  of  posterior  rhinoscopy. 

In  the  differential  diagnosis  between  suppuration  of  the  frontal 
sinus  and  of  the  antrum  of  Highmore,  no  great  weight  can  be  laid 
upon  the  statements  of  the  patient,  for  the  symptoms  of  the  two 
affections  may  be  very  similar.  Particularly  spontaneous  frontal 
headache  and  neuralgic  symptoms  in  the  first  and  second  divisions 
of  the  trifacial  are  observed  without  distinction  in  disease  of  either 
sinus. 

The  most  reliable  means  for  diagnosis  Avith  reference  to  the  seat 
of  suppuration  is  irrigation  of  the  tAvo  cavities  through  the  middle 
meatus.  If  tlie  cannula  with  an  S  curve  cannot  be  introduced,  the 
anterior  portion  of  the  middle  tin-binate  may  be  removed  under  local 
anesthesia,  so  as  to  expose  the  ducts  of  the  antrum  and  of  the  frontal 
sinus.  As  the  result  of  the  local  anemia  which  follows  cocaine  anes- 
thesia and  the  removal  of  the  remnants  of  secretion  and  of  dried  crusts, 
pus  usually  appears  at  one  or  the  other  orifice;  but  that  cavity  alone 
is  diseased  from  which  pus  flakes  or  clots  may  be  washed  out,  and  from 
which  after  irrigation  no  more  pus  appears.  To  confirm  the  diagnosis, 
oral  transillumination  is  of  service.  If  an  electric  lamp  is  introduced 
into  the  mouth  in  a  dark  room,  the  normal  frontal  sinus  and  antrum 
are  distinguished  from  their  surroundings  by  a  rosy  illimiinated  area, 
while  in  case  of  inflammation  of  the  lining  membrane,  or,  to  a  greater 
degree,  in  the  presence  of  suppin-ation,  the  liglit  rays  are  obstructed 
and  the  opacity  in  comparison  with  the  unaffected  simis  is  striking. 
Fluoroscopic  examination  shows  a  shadow  on  the  affected  side,  and 


OPENING  UP  THE  ANTRUM  183 

should  be  employed   in  doubtful  cases  for  further  support  of  the 
diagnosis. 

OPERATIONS  ON   THE  ANTRUM 

Of  all  the  accessory  siinises  of  the  nose,  the  cavity  of  the  upper  jaw, 
the  antrum  of  Highmore,  is  most  frequently  affected.  This  is  ex- 
plained partly  by  the  unfavorable  situation  of  its  duct,  which  does 
not  originate,  as  in  the  frontal  sinus,  at  the  lowest  jioint  of  the  cavity, 
but  is  situated  in  the  wall  at  a  place  which  is  comparatively  high.  In 
the  upright  position  a  considerable  amount  of  secretion  may  collect 
in  the  antrum  before  the  surface  reaches  the  level  of  the  exit.  The 
frequency  of  eni{)yema  of  the  antnmi  is  increased  by  the  fact  that  it 
residts  not  only  from  inflammatory  affections  of  the  nose,  but  also 
from  carious  teeth. 

OPENING  A   SINGLE   ANTRUM 

While  acute  suppuration  of  the  antrum  usually  disappears  under 
local  applications  and  irrigation,  chronic  inflammation  demands 
operative  exposure  of  the  cavity,  removal  of  the  diseased  mucous 
membrane  and  the  institution  of  favorable  drahiage.  The  longer  the 
disease  lasts,  the  smaller  is  the  outlook  for  cure  without  operation. 

According  to  the  method  of  Kiister,  the  antrum  may  be  opened 
through  the  canine  fossa  of  the  alveolar  process,  the  mucous  membrane 
of  the  mouth  and  the  periosteum  being  divided  transversely  or  from 
above  downward,  and  the  anterior  wall  of  the  antrum  drilled  and 
removed.  It  is  of  advantage  to  enlarge  the  exit  into  the  nose  from 
within  the  cavity,  in  order  to  procure  faA^orable  conditions  of  drain- 
age. This  is  done  by  the  method  of  Cadwcll-Luc,  by  which  dressing 
forceps  are  ])assed  from  the  antrum  thi'ough  the  lateral  wall  of  the 
nose  into  the  nasal  cavity,  and  the  bony  partition  is  removed  down  to 
the  palatal  process.  Resection  of  the  lower  and  anterior  portions  of 
the  middle  turbinate  should  not  be  omitted.  The  following  observa- 
tion may  serve  as  an  example  of  the  operation  for  inii'alcral  on pi/onn 
of  the  antrum: 

A  very  deaf  sixty-year-old  woman  stated  that  for  fifteen  years  she 
had  suffered  from  headaches,  which  were  focused  in  the  forehead  above 
the  right  eye.  At  first  the  ))ain  came  infrciiuently,  then  it  came  as 
often  as  every  eight  days,  particularly  in  the  evening,  and  lasted  until 
midnight.  She  felt  as  if  a  nail  with  a  large  head  were  sticking  in  her 
skull.    On  the  same  side  there  were  disturbances  in  hearing,  roaring 


184  SURGERY  OF  THE  NOSE  AND  SINUSES 

and  ringing  in  the  ear.  The  attacks  at  first  were  unbearable,  but  later 
increased  niarketlly  in  intensity  and  duration  until  her  physician  sus- 
pected brain  tumor.  But  on  examination  no  signs  of  this  were  found. 
On  the  other  hand,  the  X-ray  demonstrated  a  shadow  over  the  right 
antrum,  and  transillumination  in  a  dark  room  showed  that  all  the 
accessory  sinuses  were  transparent  excej^t  the  antrum;  accordingly, 
although  the  statement  of  the  patient  pointed  toward  the  frontal 
sinus,  the  right  antrum  was  opened. 

A  large  sponge  was  packed  in  the  right  loAver  cheek  pouch  and 
a  strip  in  the  right  posterior  nasal  orifice.  The  right  upper  lip  being 
retracted  upward  and  the  corner  of  the  mouth  outward  (Fig.  213, 
Plate  40) ,  incision  was  made  through  mucous  membrane  and  periosteum 
at  the  top  of  the  canine  tooth  jjarallel  to  the  edge  of  the  gum  down  to 
bone,  so  that  a  strip  of  mucous  membrane  of  the  gum  about  1  cm.  wide 
remained.  JMucous  membrane  and  periosteum  were  stripped  upwards 
with  the  raspatory  until  the  anterior  wall  of  the  antrum  was  exposed 
from  incisors  to  the  first  molar.  Thereupon  opening  was  made  with 
a  gouge  and  enlarged  with  rongeurs  until  the  index  finger  could  be 
inserted  comfortably.  Upon  opening  the  mucous  membrane  a  polyp- 
like formation  projected  which  had  to  be  removed  with  a  curette 
(Fig.  213,  Plate  40).  The  opening  in  the  anterior  wall  was  large 
enough  to  introduce  the  curette  alongside  the  index  finger  and  to  re- 
move completely  the  hyperplastic  mucovis  membrane  lining  the  cavity. 
JMeanM'hile  there  flowed  out  a  tenacious  muco-purulent  fluid. 

With  the  left  index  finger  in  the  antrum,  a  strong  curved  dressing 
forceps  was  shoved  through  the  partition  wall  from  the  right  middle 
meatus  (Fig.  214,  Plate  40).  In  order  to  establish  wide  communi- 
cation between  the  nasal  cavity  and  the  antrum,  the  projecting  mar- 
gins of  bone  were  removed  with  chisel  and  rongeurs,  as  well  as  the 
lower  and  middle  turbinates.  The  irregularities  of  the  floor  of  the 
antrum  were  leveled  off'  with  a  gouge  (Fig.  21.5.  Plate  40)  until  the 
index  finger  could  enter  the  nasal  cavity  through  the  antrum  without 
hindrance.  After  the  antrum  had  been  freed  of  the  thickened  inflamma- 
tory mucous  membrane  and  all  the  pockets  and  hollows  were  disposed 
of,  it  was  packed  tight  with  an  iodoform  strip,  the  ejid  of  which  was 
carried  through  the  wide  passage  to  the  nose,  and  out  the  nasal  orifice. 
Periosteum  and  mucous  membrane  were  vmited  over  the  canine  fossa 
with  four  interrupted  sutures  (Fig.  216,  Plate  40)  in  order  again  to 
close  off  antrum  from  mouth.  The  packing  was  removed  through 
the  nose  on  the  foin-th  day.    From  the  day  of  operation  the  patient's 


Krause-Heymann-Ehrenfricd 


Tab.  40. 


0]ienin<^"  of  the   Antrum   of  1  li^limore. 


Right 
corner 

of 
mouth 


Aittrum  of 
H 101  mo  re 

Mitcoits  potyi}__. 


Curved 
dressing 
forceps 


Fig.  213.  Removal  of  lllu^.olI,^  polyp  with  curette. 


Fig.  214.   Tlie  lateral  wall  of  the  nasal  cavity  is  broken 
through  by  forceps  introduced  through  nose. 


Ridge  of  bone 


Stitch 


Fig.  215.  Smoothing  out  the  uneveness 
of  the  interior  of  the  cavity. 


Fig.  216.  Muco-periosteal  suture. 


^ebinan  Company,  New  \'ork. 


Krause-Heymann-Ehrenfried.  Tab.  41. 

Radical  operation  for  double  empyema  of  the  antrum,  after  the  method  of  Partsch. 


The  upper  lip   is  drawn 

upward  by  blunt  rake 

ret'rat  tors 


g.  217.    Incision    of 
mucous  membrane. 


Defect  in  teeth 

Fig.  218.  Chiseling  through  the 
bony  nasal  septum. 


Scissors 


Fig.  219.  The 
alveolar  process, 
chiseled  free,  is 

drawn  bovcn 
by  hook. 


Gauze 
packing 


Fisj.  22U.    Resection   ol    ni;ln   lower  turbinate. 


OiuiZf    strip 


Gnnzf  strip 


sat;  sit  tun' 


Fig.  221.  The  eno  ««^^ 
of  the  strip  is      \^^Pi 

brought  out  \     ^  \, 

u"onoh  the  nasal  _..     _„,,    ,,  ■     .     i       , 

orifice  '^'S-  222.  Muco-periosteal  suture. 


Rebman  Conip.Tny,  New  York. 


BILATERAL  EMPYEIMA  OF  THE  ANTRUM  185 

temperature  was  normal,  and.  as  she  complained  of  no  symptoms,  she 
was  discharged  two  weeks  later. 

OPENING  UP   BOTH  ANTRA  AFTER   THE   METHOD  OF   PARTSCH 

In  empyema  of  both  antra,  in  case  of  lar<ie  polyps  in  the  lower 
meatus,  in  bone  cysts  and  malioiiant  tumors  of  the  antrum,  opening 
up  of  both  antra  simultaneously  may  be  necessary  for  a  satisfactory 
inspection.  The  following  case  demonstrates  this  procedure,  follow- 
ing the  technique  of  Partsch.  The  magnitude  of  the  operation  is  to 
be  balanced  against  the  assurance  whicli  it  offers  that  all  of  the  affected 
tissue  may  be  removed.  In  spite  of  the  extensive  separation  of  bone, 
healing  results  without  external  scar  or  deformity. 

A  twenty-year-old  girl  suffered  for  several  years  in  spite  of  pro- 
tracted treatment  bj-  specialists  with  double  empyema  of  the  antrum, 
which  caused  severe  symptoms,  particularly  headache,  asthmatic 
attacks  and  frequent  nausea.  In  order  to  relieve  her  symptoms  it  was 
decided  to  open  up  both  antra.  The  operation  was  carried  out  with 
the  patient  in  the  half-sitting  po$ture;  the  back  was  elevated  bj'  a 
thick  roll  and  the  head  bent  over  backwards. 

After  the  u])per  lip  was  lifted  out  of  the  way  with  a  dull  rake 
retractor,  the  mucous  membrane  was  divided  transversely  exactly  at 
the  point  of  transition  of  lip  and  gum  (Fig.  217,  Plate  41).  The 
anterior  wall  of  the  superior  maxilla  was  chiselled  through  from 
before  backwards  with  a  wide  chisel  just  above  the  spine  of  the  nose, 
and  the  bony  incision  was  lengthened  at  each  side  as  far  as  the  ptery- 
goid process.  In  the  same  way  the  bony  septum  of  the  nose  was 
separated  by  chiselling  from  the  spine  backward  (Fig.  218,  Plate  41). 
The  alveolar  process  with  the  bony  palate,  Avhich  was  separated  from 
the  rest  of  the  maxilla,  was  pried  down  with  the  chisel  and  held  down- 
ward with  a  blunt  hook  (Fig.  219,  Plate  41). 

The  bleeding  which  resulted  from  this  procedure  was  controlled  by 
packing  the  antra,  now  readily  accessible,  with  strips  of  gauze.  In 
the  left  antrum  was  found  a  large  polyp,  which  was  seized  at  its 
pedicle  and  twisted  away;  the  entire  mucous  lining  of  this  cavity 
was  removed  with  the  curette  and  the  cavity  was  repacked  with  vio- 
form  gauze.  In  the  right  antrum  no  polyp  was  found,  but  the  mucous 
membrane  showed  marked  inflammatory  thickening  and  was  covered 
with  a  layer  of  pus,  so  that  it  also  had  to  be  removed  with  the  curette. 
This  antrum  was  likewise  packed  with  vioform  gauze.  In  order  to 
create  a  wide  communication  between  each  antrum  and  the  nose,  both 


186  SURGERY  OF  THE  NOSE  AND  SINUSES 

congested  lower  turbinates  were  removed  with  scissors  (Fig.  220, 
Plate  41),  and  at  the  same  time  the  lateral  walls  of  the  nose,  which 
contained  the  passage  from  the  antrum  to  the  nose,  were  removed 
Avith  chisel  and  bone  forceps. 

After  all  the  irregularities  and  pockets  of  both  antra,  particularly 
on  the  floor,  were  freed  of  inflammatory  mucous  membrane  by  means 
of  a  curette,  each  was  packed  with  a  vioform  strip,  the  tip  of  which 
was  carried  through  the  opening  in  the  lateral  nasal  wall  and  out 
through  the  corresponding  nasal  orifice  (Fig.  221^  Plate  41). 

Finally  the  separated  palatal  plate  was  replaced  in  its  original 
position,  considerable  pressure  being  exercised  in  order  to  control  the 
bleeding.  When  the  bleeding  ceased,  mucous  membrane  and  jjcri- 
osteum  were  united  with  eight  interrupted  sutures  of  silk  (Fig.  222, 
Plate  41 ) .  Since  in  this  case  both  middle  incisors  were  wanting,  at 
this  place  the  bony  alveolar  process  could  be  included  in  two  of  the 
sutures. 

On  the  second  day  after  operation,  withdrawal  of  jiacking  was 
begun,  and  by  five  days  later  removal  from  both  nasal  cavities  was 
completed.  For  several  days  thereafter  a  sanguinolent  secretion 
came  away  through  the  nose:  liut  this  disappeared  after  a  few  irriga- 
tions with  warm  boric  acid  solution.  The  sense  of  pressure  which  was 
complained  of  at  first  in  the  upper  jaw  disappeared  after  about  two 
weeks.    The  patient  has  remained  without  symptoms  since  operation. 

OPENING  UP  THE  FRONTAL  SINUS 

Empyema  of  the  frontal  siiuis  is  not  observed  as  frequently  as 
empyema  of  the  antrum.  This  is  explained  by  the  fact  that  the  drain- 
age of  the  frontal  sinus  is  carried  out  under  more  favorable  conditions 
than  that  of  the  antrum,  for  its  duct  leads  from  the  deepest  point 
of  the  sinus  downwards  in  a  straight  line  into  the  nasal  cavity. 

Indication  for  surgical  treatment  may  exist  if  as  a  result  of  the 
closure  of  this  canal  retention  of  pus  calls  forth  threatening  symptoms. 
As  such  in  acute  cases,  outside  of  the  high  fever  which  usually  occurs 
with  the  empyema  following  infectious  diseases,  and  especially  after 
influenza,  occurs  intense  headache,  and  in  very  rare  cases  extension  of 
the  suppuration  to  neighboring  parts.  This  last  complication  may 
lead  to  purulent  meningitis  or  cellulitis  of  the  orbit.  Although  both 
these  are  rare  sequelse  of  acute  empyema,  nevertheless  they  should  be 
particularly  feared  on  account  of  their  usually  fatal  termination. 

Chronic  suppuration  of  the  frontal  sinus  is  ordinarilj'  indicated  by  a 


FRONTAL  SINUITIS  187 

periodical  Iiohtin<i-  up.  It  may  run  for  a  mouth  or  more  without 
symptoms,  hut  the  symptoms  reappear  with  oreat  severity  if  as 
result  of  a  transitory  coryza  or  mild  sore  throat  the  mucous  memhrane 
of  the  duct  swells  up  and  drainage  of  the  secretions  is  interfered  with. 
Then  the  same  symptojiis  appear  as  in  acute  empyema.  Tlie  diag- 
nosis may  he  made  in  the  interim  only  by  finding  pus  in  the  middle 
meatus.  But  at  the  same  time  fever,  spontaneous  headache,  and  par- 
ticularly neuralgia  of  the  first  or  second  trifacial  branches,  and  diffuse 
edema  of  the  root  of  the  nose  may  sen^e  as  guides  to  the  site  of  disease. 
All  these  symptoms  are  apt  to  increase  in  severity  on  sneezing  or 
coughing,  or  after  overindulgence  in  alcohol.  The  statement  of  the 
patient  as  to  the  seat  of  the  spontaneous  headache  may  lead  to  mis- 
taken conclusions,  so  frontal  headache  may  frequently  e.xist  in  emjiy- 
enia  of  the  antrum.  In  doul)tful  cases  the  diagnosis  may  be  deter- 
mined by  means  of  a  shadow  in  the  X-ray  picture  or  opacity  in  the 
affected  cavity  on  oral  transillumination. 

TREPHINING  THE  ANTERIOR  WAIJ.  OF  THE  FRONTAI,  SINUS 

If  in  fresh  disease  of  the  sinus  the  attempt  to  pass  a  probe  through 
the  duct  and  to  irrigate  the  cavity  is  unsuccessful,  even  if  the  middle 
meatus  is  cocainized  or  the  middle  turbinate  removed,  as  the  simplest 
and  safest  means  to  give  exit  to  the  pus,  trephining  of  the  frontal 
simis  must  be  performed.  The  proper  incision  for  this  purpose  from 
the  cosmetic  point  of  view  is  one  placed  in  the  middle  of  the  medial 
half  of  the  eyebrow.  In  order  to  create  better  drainage  from  the 
frontal  sinus,  after  the  anterior  wall  has  been  removed  sufficiently 
\\ith  rongeurs  introduced  in  the  trephine  hole,  a  dressing  forceps 
which  is  bent  anteriorly  is  pushed  down  through  into  the  nasal  cavity 
in  the  neighborhood  of  the  naso-frontal  duct,  and  a  rubber  drain  is 
seized  and  pulled  back  through  the  nose. 

The  removal  of  the  mucous  membrane  from  all  pockets  and  irregu- 
larities of  the  sinus  with  the  curette  is  possible  only  after  the  anterior 
wall  has  been  removed  in  sufficient  extent.  As  a  result  a  flattening 
of  the  operated  side  of  the  forehead  is  noticeable  after  healing,  and  if 
operation  has  been  done  on  both  sides,  there  results  a  considerable 
deformity.  For  that  reason  extensive  resection  of  the  anterior  wall 
is  no  longer  carried  out  in  this  form,  l)ut  it  has  been  replaced  by  the 
radical  operation  of  Killian,  ])y  which  a  bridge  of  bone  is  left  to  suj)- 
port  the  arch  of  the  brow.  In  acute  em])yema  of  the  frontal  sinus, 
which  requires  drainage  for  the  retained  pus,  simple  trephining  with- 


188  SURGERY  OF  THE  NOSE  AND  SINUSES 

out  extensive  removal  of  bone  through  an  incision  in  the  eyebrow 
suffices;  in  chronic  empyema  in  which  careful  cleaning  out  of  the 
mucous  lining  and  a  leveling  of  all  unevenness  within  the  cavity  is 
decidedly  necessary,  the  radical  operation  of  Killian.  as  is  shown  by 
the  following  observation,  presents  the  most  assured  technique: 

THE   RADICAL  OPERATION   OF   KILLIAN 

A  thirty-one-year-old  patient  when  scA'en  years  old  received  a  blow 
on  the  right  side  of  the  forehead  to  which  he  refers  his  trouble.  Soon 
after  throbbing  pain  appeared  in  the  region  of  the  forehead  over  the 
right  eye.  He  was  disposed,  since  childhood,  to  stubborn  and  recur- 
rent coryza.  With  intermissions,  this  condition  over  the  right  eye 
continued  in  spite  of  internal  medication,  and  local  alcohol  injections, 
so  that  four  years  before  the  right  supraorbital  nerve  was  resected 
elsewhere.    After  operation  the  pains  returned. 

On  entrance  to  the  hospital  X-rays  showed  the  right  frontal  sinus 
considerably  larger  and  more  opaque  than  the  left.  ^Moreover,  in  the 
right  middle  meatus  was  found  a  thin,  slimy  secretion,  which,  after 
diagnostic  irrigation,  was  determined  to  come  from  the  affected 
frontal  sinus.  Accordingly  all  the  symptoms  were  referred  to  suppu- 
ration of  the  frontal  sinus.  In  order  to  induce  a  radical  cure  in  the 
patient,  who  was  psychically  depressed  from  his  long  suffering,  it  was 
decided  to  do  the  Killian  operation. 

A  skin  incision  was  made  through  the  shaved  eyebrow,  and  was 
continued  somewhat  inwards  and  downwards  upon  the  dorsum  of  the 
nose.  It  corresponded  in  part  to  the  earlier  incision  for  the  resection 
of  the  nerve.  The  upper  edge  was  retracted  (Fig.  223,  Plate  42) 
and  the  periosteum  divided  transverseh'  about  five  or  six  mm.  above 
the  supraorbital  margin;  the  lower  edge  was  likewise  retracted,  and 
the  periosteum  was  incised  below  exactly  at  the  bony  edge  of  the 
orbit,  so  that  a  small  strip  of  bone  which  corresponded  to  the  super- 
ciliary ridge  remained  covered  with  periosteum.  The  bleeding  could 
be  completely  controlled  by  tension  on  the  retractors.  The  periosteum 
was  then  stripped  upwards  from  the  superior  incision  and  downwards 
from  the  inferior  for  a  considerable  extent,  laying  bare  the  frontal 
and  orbital  walls  of  the  sinus   (Fig.  223,  Plate  42). 

A  half  centimeter  outside  the  middle  line  the  frontal  sinus  was 
opened  with  a  small  burr  drill,  which  showed  a  considerable  thickened 
wall.  By  probing  it  was  determined  that  the  sinus  passed  for  a  con- 
siderable distance  beyond  the  outer  wall  of  the  orbit.     In  order  to 


Krause-Hcymann-Ehrenfricd.  Tab.  42. 

Radical   operation   for  infection   of  the  frontal  sinus,  after  Killian. 


Prohinrr  the  frontal  sinus 


Periosteum  stripped  back 
Anterior  wall  of  frontal  sinus 


Periosteum  of  roof  of  orbit 


Upper  lid  drawn  downward 


Bony  bridge,  covered  with  periosteum 


Roof  of  orbit,  forming  floor  of  frontal  sinus 


Periosteum  stripped  back 


Fig.  223.  Exposure  of  anterior  and  orbital  \xalls  of  frontal  sinus; 
probing  the  cavity  throui^h  a  drill  hole. 


Dahlgren 
cranial  rongeurs 


Cavity  opened 
wide 

Orbital  margin 
retained 


Drill  hole 


Fig.  224.  Cutting  out  the 
anterior  wall. 


Dahlgren  cranial  rongeurs 

Fig.  225.  Resection  of  orbital  wall  of 
frontal  siiuis. 


Posterior  wall  of  frontal  sinus 


Probe 


Posterior  wa/l 
of  frontal  sinus 


Fig.  226.  Coiunuuiication  etabllshcd  with  nasal  cavity. 
Rebnian  Company,  New  York. 


Fig.  227.  Scar  after  3  weeks. 


THE  KILLIAX  OPERATION  189 

open  it  wide,  tlie  frontal  wall  was  divided  exactly  in  the  line  of  the 
upper  periosteal  incision  by  means  of  cranial  ronf)'enrs  (Fig.  224, 
I*late  42).  Mediallv  this  was  successful  without  len<>thenhiff  the  skin 
incision;  externally  the  upper  periosteal  incision  had  to  be  lengthened 
for  several  cm.  in  a  horizontal  direction  until  a  piece  of  bone  fully 
1  cm.  across  of  a  lengthened  oval  shape  representing  the  entire  frontal 
wall  was  removed  (Fig.  225,  Plate  42).  Thereupon  the  mucous 
membrane  of  the  sinus  could  be  easily  investigated;  it  showed  the 
changes  of  clironic  inflammation  and  appeared  like  a  thick  white 
membrane.  In  the  attempt  to  remove  it  by  sponging  the  unusually 
tliin  posterior  bony  wall  broke  through  in  several  places.  The  same 
thing  haj^pened  when  the  mucous  membrane  was  being  removed  with 
the  curette  from  the  medial  wall  and  the  orbital  surface. 

While  the  mucous  membrane  in  the  lateral  half  of  the  sinus  was 
being  removed,  it  was  found  that  the  paper-thin  lamelte  of  bone  com- 
prised the  anterior  wall  of  a  second  cavity  2  cm.  deep  by  4  cm.  wide, 
which  lay  externally  and  posteriorly.  After  this  partition  was  com- 
pletely broken  away  with  forceps  another  third  cavity  of  about  half 
the  size  was  found  medially  in  the  direction  of  the  sj^henoid. 

After  removal  of  the  mucous  membrane  and  bony  septa,  the  cavity 
was  packed  with  10  per  cent,  iodoform  gauze  and  the  removal  of  the 
orbital  wall  was  begun.  Here  also  the  burr  drill  and  the  cranial 
rongeurs  were  employed   (Fig.  225,  Plate  42). 

The  enlargement  of  the  bony  orifice  on  the  floor  of  the  sinus  and 
its  extension  to  the  lateral  nasal  wall  was  carried  out  with  the  ron- 
geurs, by  which  procedure  the  ethmoid  cells  were  simultaneously 
opened.  Here  the  mucous  membrane  appeared  similar  to  that  of 
the  frontal  simis,  and  it  was  removed,  together  with  the  middle  tur- 
binate, so  far  as  was  possible,  through  the  lateral  opening.  Thus  a 
wide  communication  was  established  between  frontal  siiuis  and  nasal 
cavity,  and  a  dressing  forceps  could  now  be  introduced  without  diffi- 
culty through  the  nasal  orifice  (Fig.  226,  Plate  42)  to  draw  up  a 
drainage  tube.  The  tube  was  left  together  with  a  drainage  strip  in 
the  frontal  sinus;  the  drainage  tube  alone  was  carried  out  through  tlie 
nasal  orifice,  but  the  skin  was  sewed  with  four  interrupted  sutures  over 
the  iodoform  packing  along  the  superciliary  ridge. 

Four  days  later  one  suture  was  removed  in  order  to  take  out  the 
iodoform  gauze;  to  remove  this  tlu-ough  the  nose  would  have  been  too 
painful  for  the  patient.  The  drainage  tube  was  allowed  to  remain 
for  about  one  week  longer;  at  the  beginning  it  drained  off  a  bloody 


190  SURGERY  OF  THE  NOSE  AND  SINUSES 

fluid,  but  later  a  pure  mucous  secretion.  Foin-teen  days  after  opera- 
tion the  patient  was  dischar<red  well  (Fig.  227,  Plate  42) .  Three  years 
later  it  was  determined  tliat  he  had  remained  free  of  recurrence  and 
had  not  sufi'ered  again  either  from  neuralgia  or  from  headache.  The 
woimd  had  healed  without  disfigurement  of  the  face,  and  after  the 
hairs  had  grown  again  upon  the  eyebrow,  only  the  medial  end  of  the 
incision  between  the  inner  lid  and  the  bridge  of  the  nose  was  visible. 

The  method  of  Killian  has  distinct  advantage  over  the  radical  resec- 
tion of  the  anterior  wall  of  the  frontal  sinus  from  the  cosmetic  point 
of  view.  AVith  this  operation  the  cavity  is  freel}'  exposed,  and  the 
mucous  membrane  may  be  removed  just  as  completely  as  by  other 
methods.  If  only  a  small  strip  of  bone  remains  along  the  supraorbital 
margin,  the  arch  of  the  forehead  is  not  lost,  as  is  the  case  in  other 
methods. 

Another  advantage  of  the  Killian  technique  consists  in  the  fact  that 
from  the  incision  along  the  inner  canthus  the  periosteum  may  be  re- 
moved from  the  lamina  papyracea  and  the  radical  operation  for 
chronic  suppuration  of  the  ethmoid  may  also  be  performed.  Quite 
frequently  suppuration  of  the  frontal  Sinus  is  combined  with  a  similar 
infection  of  the  ethmoid. 

In  bilateral  chronic  suppuration  of  the  frontal  sinuses  the  radical 
operation  may  be  performed  on  the  second  sinus  a  week  after  the  first, 
continuing  drainage  of  the  cleaned-out  frontal  and  ethmoid  sinuses 
through  the  nasal  orifices  for  a  somewhat  longer  period.  After  re- 
moval of  the  packing  they  are  irrigated  for  some  time  through  the 
drainage  tube,  which  is  allowed  to  remain  in  place,  with  a  mild  solution 
of  boric  acid,  in  order  to  lessen  the  secretion  of  mucus.  The  cosmetic 
residt  in  these  cases  has  been  thoroughly  satisfactory;  after  two 
months,  when  the  eyebrows  are  grown  out  again,  notliing  is  to  be  seen 
of  the  incision  except  the  extension  over  the  ethmoid  in  the  region  of 
the  root  of  the  nose. 

EXPOSURE  OF  AND  RADICAL  OPERATION  ON  THE  ETHMOID 

In  the  description  of  the  Killian  operation  the  method  of  approach 
for  chronic  suppuration,  polyps  and  tumors  in  the  ethmoid  cells  has 
already  been  shown.  If  exenteration  of  the  ethmoid  cells  without 
opening  the  neighboring  sinus  is  under  consideration,  it  may  be  carried 
out  through  an  incision  which  corresponds  to  the  medial  end  of  the 
skin  incision  for  the  Killian  operation.     AVhile  chronic  suppuration 


SPHENOIDAL  SINUITIS  191 

of  the  posterior  cells  are  usually  combined  with  the  same  affection 
of  the  frontal  and  sphenoidal  sinuses,  and  is  practically  not  to  he 
considered  as  an  independent  disease,  suppuration  in  the  anterior  cells, 
particularly  in  the  hidla  etlimoidalis,  is  more  frequently  observed.  It 
may  be  opened  successfully  endonasally  after  removal  of  the  middle 
turbinate.  But  complete  exenteration  of  the  anterior  as  well  as  the 
posterior  cells  of  the  ethmoid  with  packing  of  the  wound  cavities  may 
be  carried  out  under  clear  observation  only  after  opening  from  with- 
out. 

EXPOSURE  OF  THE  SPHENOIDAL  SINUS 

Chronic  suppuration  of  the  sphenoidal  sinus  is  likewise  usually 
combined  with  disease  of  the  neighboring  ethmoid  cells.  Tertiary 
syphilis  above  all  conditions  forms  an  important  etiologic  factor  in 
emj)yema  of  this  siinis.  Diagnosis  may  be  established  if  bj'  posterior 
rhinoscopy  pus  is  visible  on  the  roof  of  the  pharynx  or  in  the  upper 
meatus.  Exposure  of  the  sphenoidal  osteum  is  attained  after  resec- 
tion of  the  middle  turbinate  and  the  removal  of  several  ethmoid  cells. 

Suppuration  of  the  sphenoidal  sinus  is  of  less  particular  interest  to 
surgeons  than  tlie  tumors  which  occur  in  relation  to  its  walls.  ^Vith 
the  exception  of  polyjjs,  sarcoma  and  carcinoma,  there  are  in  particu- 
lar the  tumors  of  the  hypophysis,  which  involve  the  sphenoidal  sinus 
from  the  side  of  the  sella  turcica.  With  their  gradual  growth  they 
may  by  pressiu'e  completely  perforate  its  superior  wall,  so  that  they 
appear  M-itliin  the  sphenoidal  sinus  itself  or  are  separated  from  it  oidy 
by  a  thick  layer  of  bone  or  mucous  membrane.  The  nasal  approach 
to  the  hypophysis  is  the  same  as  the  technique  which  is  used  to  make 
the  sinus  accessible  in  its  entire  extent  for  tumors,  or  for  radical  opera- 
tion in  chronic  empyema.  The  following  observation  will  serve  as  an 
example  of  the  technique  of  Schloffer: 

EXPOSURE  OF  THE  SPHENOIDAI,  SINUS  AND  THE  HYPOPHYSIS  AFTER  THE 

INIETHOD  OF  SCHLOFFER 

A  man  thirty-five  years  old  suffered  for  two  months  with  attacks 
of  severe  headache,  which  lasted  over  an  hoiu",  and  as  a  rule  were  com- 
bined with  sloAving  of  the  pulse  to  36  per  minute  and  usually  with 
A'omiting.  Three  years  before  he  had  become  innoculated  with  syj)h- 
ilis.  In  the  past  year  he  liad  noticed  recurrent  swelling  of  the  nose, 
which  lasted  for  a  week  and  gradually  led  to  a  considerable  increase  in 
the  size  of  the  entire  organ,  which  was  confirmed  by  his  family.    A 


192  SURGERY  OF  THE  NOSE  AND  SINUSES 

few  weeks  before  there  had  developed  a  pronounced  feeling  of  thirst, 
but  no  bulimia  or  other  disturbances  of  nutrition.  The  potency  was 
normal.  X-rays  showed  a  mai'ked  widening  and  flattening  of  the  sella 
turcica. 

Examination  by  H.  Oppenheim  showed  double  optic  papillitis, 
slight  prominence  of  the  eyeballs,  changes  in  the  nose  and  in  the  region 
of  the  eyebrows  of  an  acromegalic  type  and  a  slight  general  weakness 
and  a  fine  tremor,  which  were  somewhat  more  pronounced  upon  the 
left.  He  considered  the  diagnosis  of  tumor  of  the  hypophysis  as  prob- 
able, with  the  limitation  that  there  might  be  present  a  serous  menin- 
gitis at  the  floor  of  the  third  ventricle,  which  had  involved  the  region 
of  the  hypophysis. 

The  operation  was  performed  in  the  half-sitting  posture  by  the 
Schloffer  method  in  direct  daylight  without  a  reflector,  under  light 
chloroform  anesthesia. 

First  the  nose  was  carried  over  to  the  right  side  of  the  face  accord- 
ing to  the  method  practiced  by  von  Bruns,  in  order  that  the  right 
hand  of  the  operator  might  work  without  hindrance.  For  this  purpose 
an  incision  was  made  through  all  the  soft  parts  down  to  bone  upon 
the  left  side  of  the  nose  at  the  point  of  transition  to  cheek ;  all  bleeding 
vessels  were  ligatured  or  twisted  off.  Above  the  incision  in  the  soft 
parts  ran  to  the  region  of  the  frontal  sinus  in  order  that  this  could,  if 
necessary,  be  laid  open  through  the  same  incision.  It  curved  over 
the  glabella  about  the  root  of  the  nose,  and  came  down  on  the  right 
side  as  far  as  the  inner  canthus  (Fig.  228,  Plate  43). 

Up  to  this  point  the  mucous  membrane  Avas  not  injured,  in  order 
that  no  blood  might  be  aspirated  by  the  patient.  After  careful  hemos- 
tasis  the  mucous  membrane  of  the  left  wing  of  the  nose  was  divided 
and  the  nasal  bones  were  cut  through  with  a  straight  chisel,  beginning 
from  below  on  the  left  side,  along  the  line  of  the  skin  wound  (Fig.  229, 
Plate  -13).  Upon  the  right  side  the  nasal  bone  was  cut  in  part  sub- 
cutaneously.  and  the  bony  septum  of  the  nose  was  divided  above  in  a 
horizontal  plane  with  bone-cutting  forceps.  Thereupon  the  nose  could 
be  tm-ned  freely  over  to  the  right  side  of  the  face  and  the  nasal  cavity 
exposed.  The  upper  part  of  the  bony  septum  was  removed  with 
strong  scissors  (Fig.  230,  Plate  43),  but  the  lower  part  and  the  entire 
cartillaginous  septum  did  not  have  to  be  removed,  since  the  operation 
proper  was  to  proceed  on  the  under  surface  of  the  base  of  the  skull. 

The  chloroform  anesthesia  was  now  interrupted  and  the  operation 
was  continued  with  local  cocain  and  adrenalin.    In  order  that  no  blood 


Krause-Heyniatin-Ehren  fried. 


Tab.  43. 


Exposure  of  Sphenoidal   cells  and   nasal   approach  to   hypoj^hysis,  after  Schloffer, 

Incision 


•■<•■' 


'A 


Nose  thickened 
as  result  of 
acromegaU 


Distorted  and  thickened 
upper  lip 


Fig.  22S.  Laying  open  tlie  nasal  cavity,  after  Brims. 


Bony  septum 


Fig.  231.  Removal  of  superior  turbinates  and 
resection  of  perpendicular  plate. 

Rcbman  Company.  New  \*ork. 


^~~~      Left  posterior 
nasal  orifice 

Fig.  232.  Exposure  of  liypophysis. 


SCHLOFFER'S  METHOD  193 

might  flow  down  the  pharynx,  both  posterior  orifices  of  the  nose  were 
packed  with  gauze  from  in  front.  To  reach  the  sphenoidal  sinus,  the 
perpendicular  plate  with  all  the  ethmoid  cells  and  both  upper  turbi- 
nates were  now  removed  with  small  rongeurs  down  to  the  base  of  the 
skull  (Fig.  231,  Plate  •43) ,  Avhile  the  lower  middle  turbinates  were  left. 
P"'ifty  mm.  behind  the  chiseled  surface  of  the  nasal  bone  the  anterior 
wall  of  the  sphenoidal  sinus  came  into  view. 

This  was  now  removed  in  comiection  with  its  mucous  membrane, 
and  thereupon  there  appeared  at  the  base  of  the  skull,  corresponding 
with  the  upper  wall  of  the  sphenoidal  sinus,  a  flat  vault  at  least  1  cm. 
square  (Fig.  232,  Plate  43).  With  forceps  this  entire  portion  could 
be  pressed  in,  and  immediately  it  sprung  back,  reminding  one  of  the 
parchment  crepitation  of  Dupuj'tren,  the  characteristic  of  myeloge- 
nous sarcoma  of  bone. 

After  a  small  sagittal  incision  was  made  with  a  knife  in  the  middle 
line  .30  cm.  behind  the  bony  root  of  the  nose  through  this  membrane,  a 
clear  fluid  came  away,  which  kept  on  flowing  drop  by  drop.  From 
the  cut  surface  on  either  side  the  thin  wall  of  the  sphenoidal  sinus 
coidd  be  removed  with  smooth  forceps,  as  it  was  composed  of  bone  as 
thin  as  paper.  Behind  this  appeared  a  grayish-red  mass,  apparently 
a  tumor.  A  venous  hemorrhage  of  considerable  extent  started  up, 
which  distiu'bed  the  view,  and  a  sponge  satiu'ated  in  suprarenin  was 
pressed  against  the  exposed  surface.  When  this  was  removed  again 
in  a  few  minutes,  the  tumor  had  protruded  further  to  the  size  of  a 
hazel  nut.  As  much  as  possible  of  this  was  removed  with  scissors  and 
forceps,  and  the  resected  portions  amounted  in  all  to  a  piece  the  size 
of  the  last  phalanx  of  the  little  finger.  Although  the  opening  in  the 
sella  turcica  was  finally  as  big  around  as  the  finger,  nevertheless  the 
tumor  could  not  be  entirely  removed.  Accordingly  the  operation  was 
discontiiuied  and  the  opening  in  the  diu'a  was  packed  with  10  per  cent, 
iodoform  gauze,  the  end  being  carried  out  through  the  nasal  orifice, 
and  the  soft  parts  were  sewed  up. 

The  optic  chiasm  did  not  come  into  the  field  of  vision.  In  this  case 
the  free-lying  surface  at  the  base  of  the  skull  was  unusually  large, 
since  apparently  the  tumor  had  caused  atrophy  of  the  sella  turcica  and 
the  neighboring  section  of  the  base  of  the  skull  through  jiressure  and 
had  made  a  pocket  downwards. 

Even  during  the  nasal  jxirtion  of  the  operation  the  pulse,  although 
the  loss  of  blood  had  been  very  slight,  became  bad,  so  that  stimulants 
had  to  be  administered.     Thereupon  it  improved,  but  several  times 


194  SURGERY  OF  THE  NOSE  AND  SINUSES 

respiration  ceased  temporarily  even  before  the  dura  was  opened.  This 
disturbance  of  respiration,  which  reminded  us  of  our  experience  with 
tumors  of  the  posterior  cranial  fossa,  gave  us  the  idea  that  the  case 
was  one  of  large  basal  tumor  of  the  brain.  This  impression  was  in- 
creased by  the  course  of  the  operation,  for  the  patient,  two  hours  after 
operation,  died  with  all  the  appearances  of  respiratory  paralysis, 
although  the  pulse  remained  strong  and  regidar  until  just  before 
death. 

Autopsy  (Professor  Ostreich)  showed  the  dura  under  strong  ten- 
sion and  translucent;  the  gyri  were  flattened.  In  the  region  of  the 
left  fissure  of  Sylvius  there  was  a  large  venous  air  bleb.  The  anterior 
pole  of  the  right  temporal  lobe  felt  hard  to  the  touch,  and  had  become 
attached  to  the  inner  surface  of  the  dura  in  the  middle  fossa.  On 
section  a  tumor  was  found  here  about  the  size  of  an  apple,  of  hard 
consistency,  with  a  streaky,  grayish-red  color.  The  hypophysis  was 
gone  and  likcAvise  a  small  portion  of  the  brain  substance  in  the  region 
of  the  olfactory  nerve.     The  arachnoid  was  everywhere  normal. 

The  hole  in  the  base  of  the  skull  was  exactly  in  the  sella  turcica  and 
was  about  the  size  of  a  nickel.  The  chiasm  was  uninjured  as  well  as 
all  the  basal  nerves.  The  hole  reached  on  either  side  to  a  few  mm.  to 
the  medial  side  of  the  optic  nerve,  exactly  at  the  place  where  it 
entered  the  optic  canal.  The  carotid  and  the  cavernous  sinus  were 
uninjured. 

What  had  projected  tumor-like  into  the  operative  field  showed  itself 
on  microscopic  examination  to  be  hypophysis  and  prolapsed  brain  sub- 
stance, while  the  tumor  in  the  anterior  pole  of  the  temporal  lobe 
showed  spindle-celled  sarcoma.  The  changes  in  the  sella  turcica  and 
the  acromegalic  symptoms  were  in  this  case  evidently  due  to  hydrops 
of  the  third  ventricle. 

The  temporary  osteoplastic  opening  of  the  nose  after  the  method 
of  Bruns  represents  exactly  the  operative  procedure  which  renders 
approachable  for  extirpation  new  growths  starting  from  bone  or  from 
nasal  mucous  membrane  which  have  developed  within  the  cavity  of 
the  nose.  Among  these  are  fibromatous  polyps  which  are  situated  in 
the  orifices  of  the  accessory  sinuses,  chondromata  and  osteomata,  and 
further  the  malignant  tumors  which  always  demand  radical  removal. 
Usually  the  polypoid  proliferation,  mucous  polyps,  may  be  removed 
by  the  endonasal  route  in  a  simple  and  considerate  manner;  but  ex- 
tensive deep-rooted  fibromata   may  be  removed  under  satisfactory 


KILLIAN'S  APPROACH  TO  THE  HYPOPHYSIS  195 

observation  like  malignant  tumors  only  after  wide  exposure  of  the 
nasal  cavity,  or,  if  they  have  attached  themselves  to  the  naso-pharynx, 
after  temporary  resection  of  the  upper  jaw. 

kilxian's  septum  resection  and  the  approach  to  the  hypophysis 
after  the  method  of  hirsch 

Another  nasal  method  for  reaching  the  sphenoidal  cells  and  the 
hypophysis  is  described  by  Oscar  Ilirsch.  It  begins  with  a  prelim- 
inary operation  which  has  been  devised  by  Killian  for  the  correction 
of  deviation  of  the  septum.  The  procedure  is  described  by  Hirsch 
as  follows:* 

"The  mucous  membrane  of  the  septum  is  painted  on  both  sides 
with  a  20  per  cent,  solution  of  cocain,  and  both  sides  are  then  infil- 
trated over  their  entire  extent  with  Schleich  solution.  Along  the 
anterior  edge  of  the  cartilaginous  septum  the  mucous  membrane  of 
one  side  is  incised  down  to  cartilage,  and  is  stripped  up  by  means  of 
the  raspatory,  together  with  the  perichondrium,  tliat  is  to  say  peri- 
osteum of  the  cartilage,  back  to  and  over  a  portion  of  the  bony  septum. 
Hereupon  the  cartilage  is  divided  l/>  cm.  from  its  anterior  edge 
through  an  incision  running  parallel  with  the  anterior  edge  of  the 
cartilage,  taking  care  not  to  injure  the  mucous  membrane  on  the 
opposite  side.  Between  the  cartilage  and  this  nnicous  membrane  a 
raspatory  is  introduced,  and  the  mucous  membrane  is  freed  on  this 
side  also  from  cartilage  and  bone.  By  means  of  the  branches  of  the 
nasal  speculum  the  two  leaves  of  mucous  membrane  are  held  apart, 
and  in  this  way  a  medial  cavity  is  created  in  the  nose,  in  which  on 
both  sides  the  cartilage,  stripped  of  its  mucous  membrane,  is  visible. 
This  is  removed  by  one  cut  of  a  cartilage  knife,  whereupon  the  vomer 
and  the  perpendicvdar  plate  of  the  ethmoid  are  resected  in  large  part 
with  l)one  forceps.  So  far  the  operative  procedure  is  identical  with 
the  submucous  resection  of  Killian. 

"To  expose  the  anterior  wall  of  the  sphenoidal  sinus,  it  is  necessary 
that  the  mucous  membrane  on  l)()t]i  sides  of  the  origin  of  the  vomer 
on  the  sphenoid  ])e  lifted  away.  This  ma}'  be  done  readily;  when  this 
stripping  up  is  ended,  one  can  reach  the  anterior  surface  of  the  sphe- 
noid, and  here  also  can  raise  tlie  mucous  membrane  on  both  sides  until 
the  raspatorj^  falls  through  the  sphenoidal  osteum  into  the  sphenoidal 
sinus.  Now  within  the  mucous  membrane  sack  tlic  posterior  portion 
of  the  vomer  and  the  sphenoid  is  broken  through  with  a  few  blows  of 

*Endonasal  operations  for  tumors  of  the  hypophysis,  Archiv  fiir  Laryngologic,  Vol.  '21,  N.  1. 


196  SURGERY  OF  THE  NOSE  AND  SINUSES 

the  chisel  and  the  opening  is  enlarged  with  a  hone  punch,  whereupon 
after  removal  of  the  partition  between  the  two  sphenoidal  sinuses,  the 
hypophyseal  tumor  is  seen  lying  free  in  its  surroundings.  After 
chiseling  open  the  sella  turcica  and  division  of  the  dura  the  hypophysis 
or  the  hypophyseal  tumor  is  completely  exposed." 


CHAPTER  12— SURGERY  OF  THE  TRIFACIAL  NERVE 

NEURALGIC  PAINS 

Of  all  peripheral  nerves,  the  trifacial  nerve  is  hy  far  the  most 
frequent  site  of  neuralgia,  that  is  to  say,  of  pains  which  come  in 
paroxysms  of  greater  or  less  severity,  and  which  limit  themselves 
at  least  in  the  ])eginning  of  the  disease  to  the  track  of  a  particular  nerve 
or  nerve  trunk.  Predisposing  etiologic  factors  apj)ear  in  many  nerves, 
such  as  the  passage  of  the  nerve  through  a  long,  bony  canal,  many 
branches  distributed  over  a  wide  field,  or  a  superficial  situation  which 
exposes  it  to  many  sorts  of  trauma. 

The  pains  are  sometimes  preceded  by  a  sort  of  aura,  such  as  itching, 
a  feeling  of  tension,  twitching  of  the  facial  nmscles,  etc.  But  usually 
they  come  suddenly  and  are  of  various  grades  of  severity.  All  tran- 
sitions occur  from  a  mild  burning  sensation  to  the  feeling  as  if  the 
face  was  being  cut  up  with  a  red-hot  knife.  In  other  cases  the  pains 
are  described  as  stabbing,  rending,  boring  and  cutting,  and  as  the  case 
proceeds  they  sometimes  attain  unbearable  severity,  so  that  the  patient 
is  driven  to  suicide.  The  attacks  appear  without  occasion,  or  they 
are  aroused  by  insignificant  causes,  such  as  touching  the  skin,  a  cold 
draught,  mimic  motions,  talking,  chewing,  swallowing,  etc.,  as  well 
as  by  psychic  excitement.  They  last  at  first  seconds  or  minutes,  and 
later  often  considerably  longer. 

They  may  repeat  themselves  as  often  as  several  dozen  times  a  day. 
In  very  severe  cases  the  interval  between  attacks  maj^  disappear  en- 
tirely, so  that  one  can  no  longer  consider  them  as  attacks.  The  night 
is  often  not  free  of  pain.  At  times  there  may  be  a  periodic  recur- 
rence of  the  pains,  for  instance,  in  the  spring-time. 

With  the  course  of  the  disease  ordinarily  the  sensitiveness  of  the 
skin  to  touch  increases;  but  there  may  be  numerous  exceptions  to  this 
rule.  At  times  there  remains  jjermanently  in  the  aff^'ected  area  a  feel- 
ing of  painful  tension. 

PAINFUL   POINTS 

Certain  points  in  the  course  of  the  affected  nerve  may  be  partic- 
ularly sensitive  to  pressiu'e;  from  these  attacks  maj"^  originate.  Pain- 
ful jjoints  may,  however,  be  lacking  in  the  most  severe  neuralgia;  at 
times,  indeed,  the  severity  of  the  pain  during  an  attack  may  be  de- 
creased by  pressure. 

19T 


198  SURGERY  OF  THE  TRIFACIAL  NERVE 

The  painfvil  points  have  their  situation  generally  in  places  where  the 
nerves  emerge  from  hony  canals  or  furrows  into  the  soft  parts,  and 
where  they  accordingly  can  be  pressed  against  an  unyielding  bone; 
also  wherever  the  nerve  trunk  passes  over  from  the  deep-lying  tissues 
to  branch  out  in  the  skin  or  mucous  membrane;  and  finally  where  the 
terminal  branches  of  two  nerves  anastomose. 

As  points  of  this  sort  we  recognize  in  neuralgia  of  the  first  division 
of  the  trifacial  the  supraorbital  point  at  the  sujiraorbital  notch,  the 
palpebral  point  in  the  upper  eyelid,  the  nasal  point  at  the  bony  wall 
of  the  nose;  in  neuralgia  of  the  second  division  the  infraorbital  point 
at  the  infraorbital  foramen,  a  point  in  the  upper  lip  to  one  side  and 
below  the  ala,  a  point  at  the  anterior  portion  of  the  temple  and  the 
cheek  point  on  the  malar  bone;  finally,  in  infra-maxillary  neuralgia 
the  chin  point  at  the  mental  foramen  and  the  temporo-maxillary  point 
just  in  front  of  the  tragus. 

A  painful  point  in  the  neighborhood  of  the  parietal  eminence  or  a 
bit  above  it,  which  often  is  particularly  sensitive  (jiarietal  point) ,  may 
belong  to  the  distribution  of  either  the  first  or  the  third  division.  As 
the  major  occipital  nerve,  and  at  times  the  minor  also,  send  branches 
to  this  place,  it  must  be  determined  by  exact  observation  which  nerve 
in  any  particular  case  is  responsible. 

This  impresses  upon  us  the  fact  that  a  number  of  described  painful 
points  may  lie  in  the  distribution  area  of  two  different  divisions  of  the 
trifacial,  which  is  explained  by  the  anatomical  property  of  anastomosis. 
Careful  examination  of  other  painful  points  and  close  observation  of 
the  cases  and  regard  for  the  history  will  generally  serve  to  determine 
the  affected  branch,  but  not  always.  For  that  reason  one  must  at  times 
remove  neighboring  branches  of  two  divisions;  for  instance,  if  pain 
is  located  exactly  at  the  corner  of  the  mouth,  the  infraorbital  nerve 
and  the  inferior  dental. 

IRR^VDIATION 

Every  sensory  branch  of  the  trifacial  nerve  may  become  attacked 
by  neuralgia.  Often  enough  the  attacks  limit  themselves  throughout 
the  entire  course  of  the  disease  to  a  definite  tei-minal  branch;  for  in- 
stance, the  supraorbital  nerve  of  the  first,  the  infraorbital  nerve  of  the 
second  and  the  mental  nerve  of  the  third  divisions.  Accordingly  one 
speaks  of  neuralgia  as  being  supraorbital,  infraorbital,  etc.  In  the  begin- 
ning the  pain  starts  usually  from  a  well-marked  point,  but  only  seldom 
does  it  remain  limited  for  any  length  of  time  to  such  place.     JNIuch 


IRRADIATION  PHENOMENA  199 

more  likely  is  it  for  the  pains  to  spread  very  rapidly  over  the  entire 
distrilnitioii  of  the  diseased  branch,  or  to  irradiate  immediately  into 
neii'liboriny  territorv. 

Usually  this  is  a  question  only  of  the  phenomenon  of  irradiation. 
This  may  involve  wide  areas;  in  disease  of  the  inferior  ilental.  for 
example,  it  may  reach  into  the  region  of  the  temple  (auriculo-tem- 
poral  nerve).  The  irradiation  pains  in  severe  cases  are  no  less  keen 
than  the  original,  and  if  the  coiu'se  of  the  disease  is  lengthy  the  patient 
loses  the  ability  to  delimit  exactly  the  region  of  the  primary  affection. 
The  pains  are  described  as  vague.  They  include  uniforndy  one  side 
of  the  head  or  face,  and  they  irradiate  even  down  to  the  neck.  At 
times  one  loses  on  examination  the  impression  that  it  is  a  question  of 
a  case  of  trifacial  neuralgia,  for  it  is  impossible  to  determine  in  which 
of  the  three  divisions  the  neuralgia  took  its  origin.  This  experience 
we  have  had  in  several  patients  in  whom  a  series  of  peri])heral  nerve 
resections  had  previously  been  done,  and  in  whom  finally  the  Gasserian 
ganglion  had  to  be  removed.  The  entire  hyperestbetic  skin  of  the 
affected  side  was  hardly  less  sensitive  to  pressure  than  the  typical 
painful  points. 

DETERMINATION  OF  THE  AFFECTED  BRANCH 

It  is  our  task  in  every  case  to  ascertain  the  nerve  or  nerves  which 
are  primarih'  affected;  in  this  we  may  be  assisted  by  the  following- 
considerations:  In  the  beginning  of  the  disease  the  painful  area  is 
likely  to  be  more  definitely  limited,  and  the  irradiation  comes  on  only 
as  the  affection  progresses.  Also  in  the  later  stages  the  attack  begins 
in  the  primarily  affected  area,  the  irradiation  pains  accompany  it  after 
a  shorter  or  longer  period,  not  infrequently  after  a  few  moments;  in 
addition,  the  latter  are  not  consistent;  they  may  remain  through  sev- 
eral attacks  or  they  may  change  their  course,  and  usually  they  are  not 
so  severe  as  the  pain  in  the  primarily  diseased  area. 

The  permanent  sensitiveness  which  persists  between  attacks  is  evi- 
denced in  the  distribution  of  the  nerve  primarily  affected.  If  the 
patient  practices  strong  pressure  in  a  certain  j)lace  for  the  alleviation 
of  ])ain.  this  is  as  a  rule  over  the  primarily  diseased  area,  and  not 
in  the  irradiation  zone.  At  times  an  injection  of  moi-phine  prevents 
the  irradiating  pains  without  stopping  the  attack,  and  in  this  way  may 
find  use  in  diagnosis.  Nevertheless,  all  the  described  characteristics 
may  be  without  value  in  severe  cases;  then  only  the  exact  investigation 


200 


SURGERY  OF  THE  TRIFACIAL  NERVE 


N.  lacrimaMs 
Ciliary  ganglion 

N.  supratrocHlearis  i 
N.  etbmoidalis 
N.  infratroclilearis    i 


N.  nasocillaris 

Sphenopalatine  ganglion 

N.  canalispterygoidei  (Vidil) 
Plexus  carotlcus  internus 
Otic  ganglion 
I        Oasserian  ganglion 


K.  eupraorbitalis 


N.  zygomatlcus 


Rami  nasales 
anteriores 


Rami  nasales 
pcsterlores 

S.  Infra- 
orbitallB 


Rami  alveolares 
superiores 


Nd.  palatini 


.Portio  major     i 

i  {-  of  Trifacial  nerve 

jPortio  minor    ) 

i      N.  petrosus  superfieialls  major 

;    N.  petrosus  superfieialls 
y  I  minor 

I    ;   Chorda  tympanl 


N.  auriculotemporalis 
N.  caroticus  Interoug- 

Plexus  meningeus 

Superior  cervical 
ganglion 

A',  dentalis  inferior 
Nn.  carotid  extern! 
'A'.  Ungualis 

Submaxillary  ganglioa 

■^Plexus  caroticus 
externus 

Plexus  maxillaris  externusj 
V  Common  carotid  artery 


A',  meo  talis 


Plexus  alveolaris  inferior 
Fig.  233 


The  Trifacial  Nerve  ;   Schematic  Drawixg  of  Its  Branches  and  Their  More  Important 

Anastomoses 

(The  nerves  shown  in  red  are  the  motor  oculi  (III)  and  the  facial  (VII)  ;  the  root 
of  the  trifacial  is  shown  by  \'.  and  the  glossopharyngeal  by  IX.  The  ganglia  of  the  trifacial, 
as   well   as   the  branches  of   the   sympathetic   system,   are   colored   blue.) 

(From  Toldt.  Anatomisch'er  Atlas,  7th  edition,   1911,  Fig.   1298,  page  859.) 

of  the  origin  of  the  pain  may  be  of  help,  just  as  the  history  may  be  of 
considerable  importance. 

If  one  can  determine  clearly  how  far  the  affected  area  reaches,  it  is 


DETERMINATION  OF  THE  AFFECTED  BRANCH 


201 


ordinarily  not  difficult,  with  the  help  of  a  knowledge  of  anatomy,  to 
determine  the  affected  nerve.  One  must  have  due  regard  for  the  law 
of  the  eccentric  phenomenon,  acconhng  to  wliich  the  sensation  that  a 
sensory  nerve  has  heen  stimulated  on  reaching  consciousness  is  always 
referred  to  the  peripheral  distribution  of  the  nerve  at  the  i)Iace  in  its 


N.  opbtbalmlcus 


N.  zygomatico 
temporalis 


N.  occipitalis 
major 


N.  zygomatlco- 
facialis 


N.  infraorbltalla ' 


N.  occipitalis 
minor 


N.  aurlcularls 
magnus 


Nn.  cervUalcs 
\  posteriores  (dor- 
y^  Bales) 


Nn.  cervlialea 
laterales  (ventra- 
les) 


Fig.  2.'54 

Scheme  of  the  Distrihition-  of  the  Sensory  Nekves  of  the  Head,  After  Fritz  Frohse 
(From   F.    Khat.se,   Die  Necrai.gie   des   Trioemini'S,  etc.,   Leipzig,   189(>,   p.    57) 
The  areas  supplied  by  the  1st  and  3d  divisions    of   the   trifacial   are   shaded,      a  ^  the 

blaelv  area,  represents  the  distribution  of  auricuhir  braneli  of  the  va<;us  in  the  concha. 


course  where  the  nerve  fibres  may  be  encountered.  Moreover,  regard 
nuist  l)e  ])aid  to  the  fact  that  according  to  our  present  anatomical 
knowledge  the  area  of  distriliution  of  single  branches  is  not  by  far  so 
clearh'  and  regularly  outhned  as  we  have  been  accustomed  to  believe. 
The  investigations  of  F.  Frohse  have  indeed  modified  our  opinions 
not  only  as  to  the  branches  of  one  and  the  same  division,  but  also  as 
to  the  relations  of  the  three  divisions  to  each  other.  Furthermore,  one 
must  have  j)roper  regard  for  the  findings  of  Zander,  according  to 
which  many  areas  are  co\ere(l  by  several  nerves.    In  spite  of  the  dilfi- 


202  SURGERY  OF  THE  TRIFACIAL  NERVE 

culties  which  these  anatomical  facts  give  rise  to,  they  give  us  a  basis 
for  the  fact  known  to  every  person  who  has  had  experience,  that  the 
area  of  distribution  of  single  nerves  is  poorly  definal)le. 

Exceptions  occur  when  branches  of  both  trifacials  are  affected,  as 
occurs  very  early  in  certain  general  diseases,  such  as  diabetes,  influ- 
enza or  certain  intoxications  (mercury  and  lead),  or  if  the  neuralgia 
passes  over  from  one  side  to  the  other.  We  naturally  except  here 
all  cases  in  which  the  neuralgia  is  caused  by  central  disease,  or  is  only 
a  symptom. 

ACCOMPANYING   MANIFESTATIONS 

During  the  attacks  there  appear  irritative  symptoms  on  the  part  of 
the  secretory,  vasomotor  and  trophic  branches  of  the  trifacial;  for  in- 
stance, reddening  of  the  conjunctiva,  increased  secretion  of  tears, 
nasal  mucus  and  saliva,  reddening  and  swelling  of  the  skin  of  the  face, 
secretion  of  sweat  and  an  increased  sensation  of  warmth.  Among  the 
trophic  disturbances  is  to  be  considered  herpes,  which  occvu's  on  the 
forehead.  The  facial  nerve  may  partake  in  the  disturbance  and  set  up 
fibrillary  contractions  and  twitching,  more  rarely  clonic  spasm.  In 
certain  cases  the  motor  portion  of  the  trifacial  is  stimulated,  causing 
contraction  of  the  muscles  of  mastication  and  of  the  muscles  of  the 
tongue. 

At  the  same  time  as  the  pain  in  the  face  there  may  appear  neuralgic 
symptoms  in  other  portions  of  the  body,  such  as  intercostal  neuralgia 
and  sciatica.  Pains  in  the  occipital  region  which  are  observed  in  tri- 
facial neuralgia  should  not  be  assumed  at  once  as  being  due  to  occip- 
ital neuralgia,  for  frequently  they  may  be  referred  to  irradiation. 

In  severe  cases  practically  the  entire  body  may  be  involved.  The 
patient  trembles,  cardiac  activity  is  stimulated  and  the  general  sensi- 
tiveness is  increased.  There  is  nausea  and  often  vomiting.  At  times 
one  observes  slowing  of  the  pidse. 

THE  TERMINATION  OF  NEUEAT.GIA  AND  RELAPSES 

Trifacial  neuralgia  ends,  if  recovery  occm-s  without  operation, 
usually  not  all  at  once,  but  as  a  rule  the  pains  disappear  gradually 
after  fluctuations  up  and  down.  After  successfid  operative  proced- 
ures also  the  neuralgia  does  not  disappear  at  once,  but  usually  the 
attacks  recur  at  times  in  the  first  few  days,  growing  less  severe  and 
of  shorter  duration  until  they  finally  disappear.  This  property  is 
observed  only  in  peripheral  nerve  operations;  in  extirpation  of  the 


DIAGNOSIS  OF  TRIFACIAL  NEURALGIA  203 

Gasserian  ganglion  the  neuralgic  pains  always  disappear  with  the 
awakening  from  the  anesthetic. 

Trifacial  neuralgia  tends  to  relapse  and  recurrences  are  common, 
particularly  after  all  peripheral  nerve  resections,  no  matter  by  what 
method  thev  have  been  carried  out.  As  a  rule  these  affect  the  oriffinal 
nerve  distribution,  but  at  times  they  include  other  branches  of  the 
same  division,  or  even  the  entire  division.  The  severity  of  the  pain 
in  recurrences  is  usually  decreased,  and  this  fortunate  circumstance 
may  spare  us  further  operative  procedures.  In  other  cases  the  severity 
equals  that  of  the  earlier  attacks,  and  they  maj^  reach  a  frightful  de- 
gree and  irradiate  out  into  an  ever-increasing  area. 

DIAGNOSIS   OF  NEURALGIA 

In  diagnosis  one  considers  the  picture  as  a  whole  and  is  not  swayed 
in  his  judgment  by  one  or  another  isolated  symptom.  The  beginning 
of  the  disease  is  to  be  investigated  closely,  because  at  this  time  the 
symptoms  are  much  more  clearly  defined  than  after  the  condition  has 
long  continued.  Attention  should  be  directed  in  every  case  as  to 
whether  or  not  any  disease  of  the  accessory  sinuses  or  teeth,  tumors  in 
the  peripheral  course  of  the  nerve,  or  within  the  cranium  in  the  region 
of  the  trifacial  may  be  present  and  cause  the  neuralgia,  which  will  then 
be  only  a  symptom  of  the  underlying  disorder.  In  the  same  way 
aneurysms  in  the  arteries  of  the  head,  particularly  the  internal  carotid 
near  the  Gasserian  ganglion,  or  syphilitic  disease  of  bone  and  peri- 
osteum may  set  up  or  imitate  nem-algia. 

Mention  should  also  be  made  of  ueuritic  processes,  neuralgia  in 
hysterics,  headache  and  migrain,  which  may  offer  considerable  diffi- 
culty in  differentiation  from  idiopathic  neuralgia.  Each  of  the  three 
divisions  of  the  trifacial  sends  a  branch  to  the  dura  mater  to  sup2)ly 
it  with  sensory  fibres.  It  does  not  seen)  improbable  that  tlicse  branches 
also  may  become  affected  as  in  neuralgia,  and  that  certain  types  of 
headache  result  therefrom. 

PROGNOSIS  OF  NF.ITUAI.GIA 

Trifacial  neuralgia  in  itself  is  not  dangerous  to  life,  and  one  is  ever 
astonished  that  people  who  suffer  from  a  severe  form  of  the  disease 
seem  reasonably  well  and  in  a  good  state  of  health,  lint  as  a  result 
of  insufficient  nourishment,  it  is  not  infrequent  that  a  severe  cachexia 
develops.  Those  in  whom  attacks  occur  at  night,  preventing  sleep, 
suffer  much  more  than  others.    Death,  so  far  as  we  know,  has  never 


204  SURGERY  OF  THE  TRIFACIAL  NERVE 

been  observed  in  a  neuralgic  attack,  except  in  the  presence  of  some 
organic  disease  of  the  brain;  but  these  cases  cannot  be  classified  with 
pure  neuralgia.  Loss  of  strength  makes  the  organism  on  the  whole 
less  resistant  to  intercurrent  affections  and  increases  their  danger,  but 
nevertheless  manj'  patients  in  spite  of  the  severest  suffering  reach  an 
advanced  age. 

Prognosis  depends  entirely  on  the  cause  of  the  neuralgia.  If  this 
may  be  removed,  one  may  under  skilful  treatment  in  many  cases 
induce  a  cure.  Commonly  the  prognosis  is  more  favorable  if  the 
neuralgia  is  of  short  standing  and  if  it  occurs  in  a  young,  well-nour- 
ished person.  The  outlook  for  cure  is  poorer  if  the  disease  is  well 
settled,  the  attacks  frequent  and  severe,  and  the  patient  exhausted  and 
frail. 

Under  operative  treatment  the  prognosis  as  a  rule  is  better  in  many 
respects.  But  one  is  still  frequently  met  with  the  opinion  that  opera- 
tion should  be  considered  only  after  all  other  means  have  been  ex- 
hausted. This  point  of  view  should  be  strongly  opposed.  Likewise 
one  frequently  comes  in  contact  with  patients  who,  after  thej'  have 
been  left  in  the  lurch  by  all  methods  of  internal  medication,  have  de- 
scended to  the  frequent  use  of  morphine  by  advice  even  of  well-known 
nerve  specialists,  who  hesitated  to  turn  them  over  to  the  svu'geon.  The 
morphinism  is  about  as  bad  as  the  disease  itself;  and.  above  all,  mor- 
pliine  supplies  only  temporary  relief  in  severe  cases. 

ETIOLOGY  OF  NEURALGIA 

A  neuropathic  taint,  exhausting  disease  with  the  resulting  anemia 
and  cachexia,  prematiu-e  old  age,  and  above  all.  arteriosclerosis,  play 
a  role  in  the  etiology  of  this  condition;  men  and  women  in  the  prime 
of  life  are  equally  affected.  ]\Iany  infectious  diseases  may  induce 
neuralgia,  particularly  intermittent  fever,  which  does  not  infrequently 
give  rise  to  supraorbital  neuralgia.  Of  the  acute  infectious  diseases, 
influenza  is  most  frequently  followed  by  typical  neuralgia,  and  this 
affects  usually  the  supraorbital  and  less  frequently  the  infraorbital 
nerve ;  facial  neuralgia  is  also  observed  after  typhus  fever  and  small- 
pox. 

Certain  poisons  after  long  absorption  work  the  same  result;  among 
others,  mercury,  lead,  alcohol,  nicotine.  The  neuralgia  Avhich  develops 
in  diabetes  and  gout  may  be  referred  to  a  faulty  blood  and  lymph  cir- 
culation. In  diabetes  the  third  division  is  particularly  affected,  and 
frequently  on  l)oth  sides. 


ETIOLOGY  OF  TRIFACIAL  NEURALGIA  205 

Amon^  tlie  chronic  infectious  diseases  syphilis  should  be  considered, 
especially  in  so  far  as  it  gives  rise  to  periosteal  thickenino-.  In  the 
bony  canals  the  nerves  arc  crowded  rather  closely,  and  there  is  room 
besides  for  only  the  nerve  sheath,  the  accompanying  vessels  and  the 
thin  periosteal  layer.  Under  these  conditions  even  the  slightest  swell- 
ing must  result  in  pressure.  This  refers  particularly  to  the  smaller 
canals,  such  as  those  for  the  dental  nerve,  the  zygomatico-temporal 
and  the  zygomatico-facial  canals,  etc.  Moreover,  the  nerve  itself  or 
its  sheath  may  be  attacked  by  the  specific  inflammation,  and  at  times, 
particularly  in  the  beginning  of  the  disease,  it  is  impossible  to  make 
any  other  diagnosis  than  that  of  neuralgia.  Indeed,  it  has  not  yet 
been  determined  whether  a  true  neiu'algia  may  occur  as  a  result  of 
syphilis.  Syphilitic  inflammation  of  the  membranes  of  the  brain 
should  also  be  mentioned. 

Rheumatism  and  exj^osure  play  a  role  in  the  etiology,  and  also  dis- 
turbances of  digestion  and  chronic  constipation.  Finally,  among  the 
causes  should  be  named  chlorosis,  diseases  of  the  pelvic  organs  in 
women  and  mental  emotion.  In  many  patients  the  neuralgia  is  laid 
to  injury  of  the  bones  of  the  face  or  skull. 

CENTRAL  OR  PERIPHERAL  SEAT  OF  THE  NEURALGIA 

It  is  very  important  to  know  whether  the  cause  of  the  neiu'algia 
has  its  seat  in  the  brain  or  in  the  periphery.  If  changes  are  to  be 
observed  in  the  pcri])hery  which  we  know  cTupirically  to  induce  pain, 
such  as  scars,  foreign  bodies,  tumors,  one  is  justified  in  seeking  here 
the  cause.  IT  the  neuralgia  has  come  on  in  a  definite  portion  of  the 
face  after  a  severe  cold  or  injury,  and  it  limits  itself  to  this  region, 
one  may  determine  in  favor  of  a  peripheral  location.  But  one  must 
always  remember  that  nerve  changes  once  instituted  may  advance 
along  the  nerve  to  the  brain  itself. 

Ordinarily,  in  accorchmce  with  the  law  of  eccentric  manifestations, 
the  cause  is  to  be  sought  the  higher  up,  the  more  branches  of  a  division 
are  really  affected,  excluding,  of  course,  the  area  of  irradiation.  Ac- 
cordingly, in  the  unusual  event  that  all  three  roots  were  affected  from 
the  beginning,  it  may  be  stated  with  some  certainty  that  the  disturb- 
ance exists  within  the  cranium.  Here  it  may  be  located  near  the  an- 
terior portion  of  the  ganglion,  where  the  three  trunks  lie  close  to  each 
other,  or  in  the  '••anylion  itself,  or  still  further  centrad,  in  the  course 
of  the  sensory  root  from  the  nucleus.     The  same  effect  may  be  pro- 


206  SURGERY  OF  THE  TRIFACIAL  NERVE 

duced  by  periostitic  processes  which  occur  in  the  middle  fossa  and 
involve  all  three  roots. 

But  in  case  as  ordinarily  the  neiu'algia  is  limited  to  one  or  a  few 
branches,  one  cannot  always  determine  definitely  that  the  cause  is 
peripheral.  Even  when  tumors  or  aneurysms  of  the  internal  carotid 
compress  the  trifacial  in  its  intracranial  course,  only  certain  branches 
may  show  neuralgic  symptoms.  The  motor  root  resists  the  injurious 
pressure  longest,  and  even  the  sensory  fibres  are  not  affected  equally, 
for  at  times  in  such  cases  instead  of  neuralgia,  anesthesia  develops  in 
the  trifacial  region. 

If  at  the  same  time  a  patient  shows  signs  of  cerebral  disease,  one 
frequently  refers  the  neuralgia  to  a  central  cause;  but  this  assump- 
tion is  often  ungrounded,  for  there  may  be  no  connection  between  the 
neuralgia  and  the  brain  disease.  In  other  cases,  in  spite  of  the  absence 
of  all  cerebral  symptoms,  even  if  the  condition  has  lasted  for  years, 
the  cause  may,  nevertheless,  exist  within  the  cranium.  This  short  con- 
sideration demonstrates  how  difficult  is  the  localization  of  the  seat  of 
the  causative  agent,  and  how  frequently  it  is  really  impossible. 

GENERAL  TREATMENT  OF  NEURALGIA 

Before  instituting  treatment,  one  should  attempt  to  determine  the 
cause  in  each  case.  If  successful,  treatment  should  be  directed  along 
this  line.  To  determine  the  cause,  the  history  is  of  some  value,  but 
of  more  importance  is  a  careful  investigation  of  all  the  organs  from 
which  we  know  empirically  that  the  disease  may  originate.  To  this 
group  belongs  the  teeth,  the  ear,  the  eyes  and  the  accessory  sinuses. 
Even  in  teeth  which  are  externally  sound,  exostosis  of  the  root  may 
be  present  and  give  rise  to  neuralgia.  The  neuralgia  which  originates 
from  the  sclerosis  of  toothless  gums  may  be  relieved  by  resection  of 
the  alveolar  process.  If  supraorbital  neiu'algia  is  caused  by  frontal 
sinuitis,  relief  may  be  obtained  by  the  regidar  use  of  nasal  douches 
(lukewarm  7  10  per  cent,  salt  solution  or  3  per  cent,  boric  acid  solu- 
tion). Chronic  inflammations  of  the  nose  and  catarrh  of  the  middle 
ear  must  be  submitted  to  the  regidar  form  of  treatment. 

If  splinters  of  bone  are  left  after  extraction  of  teeth,  or  if  foreign 
bodies,  scars  or  tumors  are  present  in  the  coin-se  of  the  nerves,  atten- 
tion should  be  directed  at  once  to  their  removal. 

The  use  of  morphine  should  be  avoided  entirely  in  chronic  cases. 
The  danger  of  habit  formation  is  particularly  great  in  long-standing 
cases.    One  should  not  delude  one's  self  with  the  purpose  of  giving  a 


ALCOHOL  INJECTIONS  207 

few  hours  of  peaceful  sleep  to  the  unfortunate  sufferer.  The  drug  in 
really  severe  cases  of  neuralgia  ^ives  relief  for  only  a  short  time,  and 
even  large  doses  rapidly  lose  their  effect,  and  then  as  a  permanent 
sequel  the  morphine  habit  persists.  Surgery  possesses,  even  if  medical 
treatment  fails,  a  series  of  procedures  which  offer  aid  to  the  patient, 
and  in  the  worst  eases  the  final  and  most  serious  operation,  the  removal 
of  the  Gasserian  ganglion,  is  always  to  be  given  consideration  prior 
to  the  continued  use  of  morphine. 

ALCOHOL  INJECTIONS 

As  in  sciatica,  we  have  attempted  to  relieve  trifacial  neiu'algia  by 
means  of  the  injection  of  anesthetic  agents.  In  the  first  and  second 
divisions  of  the  trifacial  Lange  injected  30  to  .50  cc.  of  salt  solution 
under  strong  pressure  into  the  nerve  sheath  or  the  immediate  neigh- 
borhood, in  order  to  cause  separation,  stretching  or  mechanical  tear- 
ing of  the  fibres.  The  proportion  of  cures  was  small,  and  so  Schlosser 
employed  80  per  cent,  alcohol  and  injected  2  to  4  cc.  directly  into 
the  diseased  nerve  trunk  with  the  purpose  of  killing  it  by  inducing 
degeneration  and  absorption  of  all  but  the  neurilemma.  This  method . 
offered  a  substitute  for  nerve  resection. 

The  enthusiastic  adherents  of  this  method  believed  that  all  periph- 
eral trifacial  resections  could  be  satisfactorily  rei^laced  by  alcohol  in- 
jections. There  can  be  no  longer  any  question  of  this;  for  in  the  last 
few  years  many  patients  have  come  with  the  in\gent  request  for  opera- 
tion, in  whom  alcohol  injections  have  been  made  by  exjjerienced  men, 
at  first  with  result,  but  after  repeated  relapses  with  less  result,  and 
finally  without  any  effect.  True  neuralgia  can  be  treated  effectively 
only  by  operatiAC  methods,  and  frequently  only  by  very  radical  meth- 
ods; for  many  ])atients  who  have  been  under  treatment  for  years,  and 
in  whom  all  methods  have  been  employed,  come  to  the  surgeon  with 
the  determination  finally  to  be  rid  of  a  disease  which  is  driving  them 
to  suicide.  Of  IS^  patients  operated  upon  up  to  April,  1907  (Krause), 
not  less  than  17  had  made  previous  attempts  at  suicide. 

The  Schlosser  method  is  indeed  a  great  advance,  and  after  its  em- 
ployment many  neiu-algics  have  doubtless  experienced  lasting  relief 
from  pain.  The  method  should  be  practiced  more  frequently,  in  so 
much  as  it  renders  the  peripheral  branches  readily  accessible  without 
danger.  .Somewhat  more  difficult  is  the  basal  injection  of  the  second 
root  at  the  foramen  rotundum,  and  of  the  third  root  at  the  foramen 
ovale.     Whoever  knows  anatomy  may  find  these  places  with   the 


208  SURGERY  OF  THE  TRIFACIAL  NERVE 

cannula  without  difficulty  (see  p.  42).  To  inject  alcohol  into  the 
Gasserian  ganglion  is,  however,  too  rash  a  procedure,  and  likewise 
the  hranches  which  run  through  the  orbit  must  be  excluded,  since  the 
eye  muscles  and  probably  the  optic  nerve  might  readily  be  injured. 


PERIPHERAL  OPERATIOXS 

GEXERAI,   ANESTHESIA   AND   LOCAL   ANESTHESIA 

Neither  in  peripheral  resection  of  the  branches  of  the  trifacial  nor 
in  extirpation  of  the  Gasserian  ganglion  is  general  anesthesia  uncon- 
ditionally necessary.  All  the  ojierations  under  consideration  may  be 
carried  out  by  means  of  novocain  and  adrenalin  anesthesia  with  com- 
plete success,  and  for  the  region  of  the  trifacial  it  is  to  be  particularly 
recommended.    For  the  technic  see  the  chajjter  on  Anesthesia,  page  42. 

Xevertheless,  there  are  many  patients  who  earnestly  request  gen- 
eral anesthesia,  since  through  this  most  jiainful  of  all  diseases  their 
capability  of  resistance  has  been  so  decreased  that  they  can  no  longer 
stand  the  psychic  excitement  which  any  operation,  even  if  carried 
out  painlessly,  induces.  In  such  cases  we  have  never  exercised  any 
pressure,  but  have  always  given  general  anesthesia  the  preference, 
excluding  only  cases  in  which  it  is  contraindicated  by  the  presence  of 
uncompensated  heart  disease  or  lung  or  kidney  affections.  Just  the 
most  severe  type  of  neuralgia  is  often  accompanied  by  arteriosclerosis, 
and  according  to  accepted  opinion  it  is  even  caused  by  this  condition, 
so  that  general  anesthesia  is  not  infrequently  contraindicated.  With 
the  aid  of  local  anesthesia  one  can  consistently  extend  the  indications 
for  radical  operation  on  the  branches  of  the  trifacial,  and  particularly 
also  for  extirpation  of  the  Gasserian  ganglion,  much  further  than  in 
the  time  when  we  were  limited  to  general  anesthesia  alone. 

INDICATIONS 

Operative  treatment  should  not,  as  so  commonly  happens,  be  con- 
sidered the  last  refuge.  There  is  no  question  but  that  as  a  result  of 
this  attitude  many  patients  who  could  have  been  cured  at  the  begin- 
ning by  comparatively  simple  procedures  lose,  in  great  measure,  their 
chance  of  relief  through  long  continuance  of  the  disease.  The  neural- 
gic changes  which  at  first  lie  peripherally  in  the  nerve  steadily  advance 
centrally,  and  finally  in  deep-seated  cases  no  extra-cranial  operation 
can  be  of  lasting  value.     We  can  expect  cure  earher  if  the  origin  of 


NERVE  EXTRACTION  209 

the  iieuralfi;ia  can  be  located  in  the   re<^i()n  of   the  peripheral  dis- 
tribution. 

The  detcnnination  as  to  which  nerve  should  be  removed  is  not 
always  simple.  Irradiating  ])aiiis  may  render  tiic  cpiestion  a  difHcult 
one  to  sohe.  as  we  have  already  shown.  A  good  knowledge  of  ana- 
tomical relations,  a  careful  consideration  of  history,  as  well  as  an 
exact  observation  of  the  attacks,  are  unconditionally  necessary  before 
the  decision  should  be  made.  As  a  general  rule  it  may  be  stated  that 
the  peripheral  branches  must  be  followed  up  from  the  smallest  to  the 
place  where  all  the  branches  which  are  affected  bj^  the  neuralgia  have 
united  into  one  trunk ;  and  at  this  point  the  division  should  be  made  as 
early  as  possible. 

EXTRACTION  OF  NERVES 

The  extirpation  of  nerves  centrallj^  as  well  as  peripherally  is  the 
object  of  the  nerve  extraction  introduced  by  Thiersch.  The  affected 
nerve  is  exposed  in  its  surroundings,  and  without  being  divided  is 
seized  crosswise  by  a  clamp,  which  will  grasp  the  nerve  securely  and 
not  allow  it  to  slip.  A  clamp  ridged  longitudinally  is  satisfactory, 
provided  the  ridges  are  not  sharp  enough  to  cut  through  or  crush  the 
nerve  fibres.  The  nerve  being  securely  grasped,  the  clamp  is  rotated 
slowly  on  its  long  axis,  according  to  Thiersch,  about  a  half  turn  every 
second,  but  it  may  be  slower  still  with  advantage.  This  procedure 
causes  the  peripheral  section  to  be  twisted  out  down  to  the  finest  ter- 
minal branches.  Of  the  central  portion  one  usually  gets  a  ])iece  about 
3  or  3l'o  cm.  long  if  it  runs  through  soft  tissues  and  is  not  closely 
attached  to  a  bony  canal;  it  usually  tears  after  this  much  has  been 
removed.  It  is  to  be  observed  that  centrally  only  those  nerve  fibres 
are  pulled  out  by  the  slow  drag  which  are  tightly  seized  in  the  clanij); 
branches  which  are  given  off  higher  are  only  torn,  but  are  generally 
not  divided.  The  best  rule  to  follow  is  to  remove  centralh*  as  much 
of  the  nerve  as  possible.  Moreover,  all  the  nerve  branches  which  run 
through  long  bony  canals  must  be  exposed  to  a  point  behind  these 
and  removed. 

How  great  an  extent  of  nerve  may  be  removed  by  this  method  is 
shown  by  the  Figs.  23.5  and  236.  Since  the  anastomotic  fibrils  of  the 
facial  nerve  are  removed  also  in  their  terminal  portions  (see  a  in 
Fig.  23.5),  it  is  not  unusual  at  times  for  paresis  to  appear,  particularly 
in  the  muscles  of  the  upper  lip  and  the  ahc  of  the  nose,  but  tliis  dis- 
appears rapidly. 


210 


SURGERY  OF  THE  TRIFACIAL  NERVE 


The  advantages  of  the  method  are  clear.  Insignificant  incisions  are 
sufficient  for  the  exposure  and  extraction  of  extensive  portions  of  the 
nerve,  and  the  operation  is  attended  with  verv  little  danger  or  sacri- 


FiG.  235 

I.  Frontal  >rerve;  II.  Infraorbital  Xerve.  Removed  after  the  method  of  Thiersch,  from 
a  78  year-oUl  i>hysioian.  Natural  size.  In  II  aljove  and  to  the  left  may  be  seen  the  be<;in- 
nings  of  the  Superior  Dental  nerves  pulled  out  at  the  same  time,  a  shows  anastomosis  of 
terminal  branches  of  Infraorbital  with  filaments  of  Facial. 


fice.  Theoretical  discussion  has  little  place  here;  tlie  best  evidence 
as  to  permanent  cure  is  offered  by  the  considerable  number  of  patients 
who  come  rei^eatedly  to  operation  to  be  freed  from  their  sufferings 
for  a  time  at  least.     Every  active  surgeon  has  had  such  experiences, 


NERVE  EXTRACTION  211 

and  W.  W.  Keen,  of  Philadelphia,  has  reported  a  case  in  which  a 
dentist  had  undergone  fourteen  operations  for  trifacial  neuralgia  dur- 
ing the  space  of  thirteen  years. 


Fig.  236 

Inferior  IMaxillarv  nerve  exposed  hy  dividinjr  tlie  ramus  of  the  jaw,  and  twisted  out  after 
the  method  of  'lliiersch,  from  a  43  yo:ir-ohl  m:ui.  Natural  size.  Ch.  t.  =  chorda  tympani 
nerve.     1  =:  linfjual  nerve,     a.  i.  =  inferior  dental  nerve. 


212  SURGERY  OF  THE  TRIFACIAL  NERVE 

RESULT  AXD  PROGNOSIS  OF  PERIPHERAL  OPERATION 

After  the  peripheral  operation — this  inchides  all  methods — the 
iieuraloic  pains  do  not  always  disappear  so  completely  that  the  patient 
on  awakening  from  anesthesia  only  feels  the  jiain  of  the  wound.  Often 
enough  in  the  first  few  days  after  operation  attacks  recur,  which  soon, 
however,  decrease  in  number  and  severity  and  finally  disappear  en- 
tirely. Clearly  the  cause  of  this  lies  in  the  injury  which  the  nerve  has 
suffered  during  the  procedure,  and  particularly  in  its  separation.  One 
should  advise  the  jjatient  of  these  possibilities  before  operation  in  order 
that  later  it  may  not  give  unnecessary  anxiety. 

In  a  few  cases,  luckily  infrequent,  the  neuralgic  pains  remain  un- 
affected by  the  peripheral  operation.  This  we  have  personally  ob- 
served twice. 

Peripheral  resection,  although  used  extensively,  is  in  many  cases 
only  a  palliative  operation.  But  the  early  as  well  as  the  later  recur- 
rences are  after  all  much  more  mild  than  the  original  disease,  so 
that  the  patient  is  satisfied  with  his  condition,  and  does  not  de- 
mand further  operation.  According  to  the  statistics  worked  out 
by  Dr.  Dege  up  to  April,  1907,  of  134  cases  operated  upon  by  one 
of  us  (Krause),  14  per  cent,  remained  free  of  recurrence.  The 
average  painless  period,  according  to  these  statistics,  lasted  two 
years  and  two  months ;  there  was,  however,  one  recurrence  after  eight 
years.  On  the  other  hand,  several  old  persons  have  died  without  ever 
having  recurrence  of  pain,  and  the  longest  painless  interval  observed 
lasted  seventeen  years,  until  death  (infraorbital  and  maTidibidar) . 
All  these  facts  refer  to  the  resection  of  peripheral  trifacial  branches. 
In  27  per  cent,  of  the  cases  the  recurrence  was  slight,  so  that  no  further 
operation  was  necessary.  ]More  than  half  the  patients  had  to  be 
operated  on  again,  and  in  not  a  few  the  Gasserian  ganglion  was  later 
extirpated. 

As  regards  the  immediate  prognosis  of  peripheral  nerve  operations, 
the  majority,  including  those  which  were  carried  out  after  the  method 
of  Thiersch,  were  trivial  procedures.  The  wounds  healed  rapidly  and 
left  insignificant  scars;  the  stay  in  the  hospital  was  limited  to  few  days. 
The  anesthesia  which  resulted  bothered  the  patient  little,  and  more- 
over in  the  course  of  time  the  area  grew  smaller  and  smaller,  with  the 
exception  that  once  after  extraction  of  the  supraorbital  nerve  we 
observed  severe  keratitis,  which  healed,  leaving  a  corneal  opacity. 

Extra-cranial  procedures  which  are  carried  out  at  the  base  of  the 
skull  are,  on  the  other  haiid.  to  be  considered  serious  operations.    Even 


Krause-Heymann-  Ehrenfried. 


Tab.  44. 


Resection   of  the  frontal   nerve. 


Su/ynwrbital  n  erve 


Branch  of  sitpraofbital 


Branch  of 
supraorbital       Supraorbital  nerve 


Fig.  237.  The  frontal  nerve  is  exposed. 


Fig.  238.  The  margin  of  the  orbit  over  tiie  foramina 
is  chiseled  away. 


Frontal  nerve 


Fig.  239.  The  trnnk  is  seized  and  torn  out. 


Fig.  240.  The  terminal  branches  are  twisted  out. 


Rcbnun  Company,  New  \ork. 


FIRST  OK   OI'HTIIAL.MIC   DI\  ISION  213 

thou<>h  life  is  only  exceptionally  endangered,  nevertheless  extensive 
scars  and  at  times  interl'erence  with  the  movement  of  the  lower  jaw 
result. 

Of  the  f>i-eat  number  of  methods  devised  and  employed  we  shall 
give  only  the  most  jjractical.  One  should  always  be  famihar  with 
several  methods  for  the  severe  operations  on  the  base  of  the  skull,  as 
the  scars  of  previous  operations  may  make  one  or  another  imjirac- 
ticable. 

During-  all  resections  of  the  trifacial  the  patient  is  held  in  the  half- 
sitting  posture. 

FIRST  OR  OPHTHALMIC  DIVISIOX  OF  THE 

TRIFACIAL 

RESECTION  OF  THE  FRONTAL  NERVE 

A  fifty-eight -year-old  woman  suffered  for  several  years  with  severe 
neuralgia  in  the  region  of  the  sujjraorbital  nerve,  due  in  all  probability 
to  arteriosclerosis.  Injections  of  alcohol  had  brouglit  temporary  re- 
lief, although  when  repeated  they  showed  themselves  to  be  useless 
for  a  permanent  cure. 

A  skin  incision  3I/2  or  4  cm.  in  length  (Fig.  237,  Plate  44)  was 
made  along  the  upper  edge  of  the  left  orbit  through  the  middle  of  the 
shaved  eyebrow.  The  supraorbital  notch,  which  could  be  palpated 
through  the  skin,  lay  about  in  the  middle  of  the  incision.  After  di- 
vision of  the  skin  and  a  few  fibres  of  the  orbicularis  palpebrarum 
muscle,  a  few  fine  twigs  of  the  supratrochlear  nerve  came  into  view, 
which  were  carefully  preserved,  so  that  by  following  them  up  one 
could  the  more  easily  reach  the  trunk;  they  were  freed  for  a  short  dis- 
tance. (Since  the  branches  of  the  facial  which  run  to  the  orbicularis 
and  the  frontalis  muscles  enter  these  muscles  from  the  outer  side,  they 
were  not  met  in  this  incision.)  Below  these  peripheral  l)ranches  the 
periosteum  was  now  incised  down  to  bone.  The  supraorbital  nerve 
was  found  to  lie  in  a  supraorbital  foramen;  the  fine  twigs  already 
mentioned  were  given  off  from  the  supratrochlear  nerve,  which  like- 
wise came  out  through  a  small  canal  at  the  edge  of  the  orbit.  In  both 
places  the  small  l)ridge  of  bone  was  removed  M'ith  a  fine  chisel  and 
hammer  (Fig.  238,  ]'late  44),  until  a  notch  remained  in  which  the 
nerve  fibres  lay  free.  (Ordinarily  the  supraorbital  notch  is  bridged 
over  only  with  stout  connective  tissue,  which  has  to  hv  cut  awaj\) 


214. 


SURGERY  OF  THE  TRIFACIAL  NERVE 

llamas  fi-oDtalla 
.Occipitofrontalis  muscle     '- 
Trochlea  \, 


Superior  oblique  muscle 


Orbicularis  palpebrarum 
muscle 

N.  supraorbit&lls 


N.  etbmoidaJis 


Orbital  periosteum 
N.  supraorbit&lla 


Levator  palpebrae 
superioris  muscle 


Superior  rectus  mutcle  /// 


[External  rectus  muscle 
N.  opticus 

if.  ophtb&lwicus 


N.  maxillaria 
superior 


N.  trochlearls 


A  sttpratrofblearis 


K  iatra.trocbleans 


tacrlmal  gland 


Basoclllarls 


Anastomotic  branch 

th  zygomatic 
nerve 


N.  menlngeus 
medius 


ddle  meningeal 
artery 


Hiatus  of  th', 
facial  canal 


H.  tentOTli 


Tentorium 
cerebelll 


N.  splnosus 


Root  of  oculo- 
motor nerve 


Root  of  troch- 
lear nerve 


Root  of  trifacial 
nerve 


Root  of  abducens 
nerve 


Inclsura  tentoril 


Straight  Binns 

Occipital  sinus 


Transverse  sinus 


Conflnens  sinuum  (torcula) 


Fig.  241 


The  FrasT  or  OpiixnALMic  Division  of  the  Trifaciai,  Nerve,  With  the  Superior  Branch 

of  the  oci  lomotor,  and  the   trochlear,  as  tlley  appear  after  removal  of  the 

Roof  of  the  Orbit 

The  nerves  supplying  the  dura  mater:  the  tentorial  nerve  (from  the  ophthalmic  division 
of  the  Trifacial),  the  meningeal  (from  the  superior  maxillary  division),  and  the  recurrent 
spinous    (from    tlie    inferior    maxillary   division). 

(On  the  left  the  upper  margin  of  the  orbit  is  left;  the  levator  palpebrae  superioris  and 
the  superior  rectus  muscles  arc  divided  at  their  origins,  and  turned  over,  to  show  the 
branches  of   the   oculomotor   entering  them.) 

(Fr<im  Toldt,  Anatomischer  Atlas,  "th  edition,  1911,  Fig.  1200.  p.  860.) 


FIRST  OI{   OPII  rilAI.MIC  DIVISION  215 

The  periosteum  was  stripjjed  back  from  the  roof  of  the  orbit  l)y 
means  of  small  sj)onf>es  of  gauze  held  by  forceps,  until  the  trunk  of 
the  frontal  nerve  was  exposed  for  a  considerable  distance  ( Fig.  2.'}0, 
Plate  44).  AN'hile  the  orbital  contents  were  carefully  held  downward 
out  of  the  wav  bv  a  retractor — one  carefully  refrained  from  tearing 
periosteum,  because  then  the  orbital  fat  would  fall  apart  and  inter- 
fere with  vision — the  nerve  trunk  was  readily  loosened  from  its  sur- 
roundings by  blunt  dissection.  It  was  grasped  with  the  nerve  clamp 
as  far  proximally  as  possible,  and  torn  out  by  a  slow,  strong  pull.  The 
peripheral  branches  were  extracted  down  to  the  finest  termini  by  very 
slowly  rolling  them  up  on  the  clamp  (Fig.  240,  Plate  44) .  From  this 
mana'inre,  through  the  tension  on  the  fine  branches,  there  resulted 
deep  folds  in  the  skin  of  the  forehead.  Hemostasis  was  attained  by 
temporary  pressure  with  gauze.  A  small  drainage  tube  was  kept  in 
the  middle  of  the  incision  for  two  days  in  order  to  anticipate  the  for- 
mation of  hematoma  in  the  orbit,  the  rest  of  the  skin  wound  being 
sutui-ed.  After  four  days  the  patient  was  discharged  without  jjain 
and  with  the  wound  healed. 

OTHEK   BRANCHES  OF  THE   OPHTHALMIC   DIVISION 

The  branches  of  the  frontal  nerve  do  not  always  come  off  in  the 
same  way.  If  one  of  them  is  left  behind  relapse  may  readily  occur. 
Therefore,  as  a  rule  the  frontal  nerve  should  be  sought  far  back  in  the 
orbit,  before  it  has  given  off  the  suj)ratrochlear  branch.  One  may 
succeed  in  freeing  the  ophthalmic  trunk  even  to  the  point  of  origin  of 
the  lachrimal  branch  by  going  back  far  enough  into  the  funnel  of  the 
orbit  aftei-  lengthening  the  incision  somewhat  externally,  but  not  to 
the  origin  of  the  nasal  nerve. 

We  can  expose  one  of  the  terminal  branches  of  the  nasal,  the  an- 
terior ethmoidal  nerve,  where  it  jjasses  through  the  anterior  ethmoidal 
foramen  at  the  inner  upper  wall  of  the  orbit,  to  reach  the  upper  sur- 
face of  the  cribriform  plate.  For  this  purpose  the  incision  is  carried  to 
the  inner  edge  of  the  orbit;  the  stripped  up  periosteum  together  with 
the  contents  of  the  orbit  are  shoved  downwards  and  outwaids.  If 
the  lachrimal  gland  interferes  it  must  l)e  ))ulled  out  from  its  recess. 
In  lifting  uj)  periosteum  the  ethmoidal  nerve  is  ])ut  on  the  stretch, 
and  is  visible  about  2  cm.  behind  the  medial  end  of  the  supraorbital 
margin;  one  can  grasp  it  in  the  clani])  and  twist  it  out. 

In  operations  on  the  medial  half  of  the  orbit  the  trochlea  or  pulley 
must  be  carefully  avoided,  in  order  to  prevent  disturbance  of  function 


216 


SURGERY  OF  THE  TRIFACIAL  NERVE 


in  the  superior  oblique  muscle  and  diplopia.     The  arteries  which  ac- 
company the  nerves  are  only  to  be  isolated  if  the  two  structures  he 


AT.  A-aots/te 


Superior  rectus  muscle 
Superior  obli/iue  muscle 


.  Bupraorbita 


\ 


Nn.  clllaros  breves 

Nn.  clUares  loDgl 


(    Levator  palpehrae  superioria 
I         muscle,  turned  back 

Ciliary  ganglion 

Radix  looga  ganglil  ciliarie 

14.  aasociliaris 

External  rectus  muscle, 
turned  back 

I   N.  opticus 

i  N.  oculomotorius 

;      /     /     N  opbtbalwicus 
I     !    I     I  Internal  carotid  artery 
I    /     ;  N. abducens 

'  Gaseerian  gaaglion 


Jtamvs  frontalis 


Rami  palpebrales   yiJ/ 
inferiores 


Branches  to  the  skin 
of  the  cheek 


Ramus  nasalis  externus 


Rami  labiales  superiores        , / 

i 

Branches  to  mucous  membrane  of  cheek 


N.  maiillariB 
superior 

maiillaris 
inferior 


Radix  bievis  ganglii  cillaris 
\  Sphenopalatine  ganglion 

X.  inf^aoTbitalis 


t    Rami  alveolares  superiores 
posteriores 


Ramus  alveolaris  superior  medius 


Branches  of  facial  nerve 


N.  den  tales 
superiores 


Ramus  alveolaris  superior  anterior 

Fig.  242 

The  Second  or  Superior  Maxillary  Division  of  the  Trifacial,  With  Its  Anastomosis 
BY  Two  Sphenopalatine  Nerves  With  the  Sphenopalatine  Ganglion,  the  Superior 
Dental  Nerves.  The  Infr.\orbital  Branch  of  the  Superior  M.^xillarv  Distributino 
Over  the  Face.  After  Leaving  the  Infraorbital  Foramen.  The  Frontal  Nerve  and 
THE  Ciliary  Ganglion,  With  Its  Branches  Going  to  the  Eye-ball,  Co.me  Off  From 
the  First  DmsioN.    Left  Side  of  the  Face,  Frosi  the  Left 

(The  skin  of  forehead  and  cheek  witli  the  siij)erfioial  muscles  of  expression  is  divided 
behind  and  turned  forward.  The  lower  jaw  is  taken  oil',  and  the  lateral  wall  of  the  antrum 
as  well  as  the  lateral  wall  of  skull  down  to  pterygopalatine  fossa  is  removed.  Levator 
palpebrae  superioris  and  external  rectus  muscles  are  divided  and  the  posterior  portions 
turned  hack.  The  quadratus  labii  superioris  muscle,  which  hides  the  bTanching  of  the 
infraorbital  nerve,  is   lifted   away  on  ,<v  hook.) 

(From    Toldt,    Anatomischer   Atlas,    Fig.    1300,    p.    SOI.) 


Krausc-Heymann-Ehrenfried. 


Tab.  45. 


Resection  of  the  infraorbital   nerve. 


re  at  thi'  infraorbital  foramen 


Fig.  243.  The  branches  of  the  nerve  are  exposed,  and  the  bony  bridge  chiseled  away. 


Mucous  membrane  of  t/ie  antrum  of  Higlimore 


Infraorbital  nerve 


Infraorbital  nerve 


Fig.  244.  The  nerve  is  exposed  witliin  tlie  orbit. 


Fig.  245.  The  peripheral  branches  are 
twisted  out. 


Rebraan  Company,  New  York. 


SECOND  OR   ST'PERIOR   :\[AXIT.I,ARV   DIVISIOX  217 

some  distance  apart,  so  that  one  can  assume  that  no  nerve  fibres 
remain  attached  to  the  vessel.  If  there  is  any  suspicion  of  this,  one 
should  grasp  botli  artery  and  nerve  in  the  clamp  and  twist  them  out 
together.     Bleeding  alwaj'S  stops  under  compression. 

In  mild  cases  of  neuralgia  one  can  employ  the  technique  of  Thiersch 
for  the  exposure  of  the  external  nasal  branch  of  the  ethmoidal  nerve. 
He  locates  it  where  it  comes  to  the  surface  through  the  pyriform 
aperture  between  nasal  bone  and  cartilage. 

After  extensive  extra-cranial  resection  of  the  frontal  nerve  and  its 
branches  in  the  manner  described,  relapse  in  the  region  of  the  first 
division  rarely  occurs  alone;  if  it  comes  at  all  it  is  y)ractically  always 
in  connection  with  pain  in  the  second  or  third  divisions,  or  in  both. 
Therefore  if  in  such  recurrences  peripheral  operation  on  these  di- 
visions remains  also  without  permanent  effect,  extirpation  of  the  Gas- 
serian  ganglion  will  have  to  be  considered. 


SECOND  OR  SUPERIOR  MAXILLARY  DIVISION   OF 

THE  TRIFACIAL 

EESECTION  OF  THE  INFRAORBITAI.  NERVE 

A  thirty-year-old  female  patient  suffered  for  two  years  with  severe 
neuralgia  confined  to  the  left  infraorbital  distribution,  for  which  she 
had  tried  numerous  methods  of  treatment  without  avail.  Exposure 
of  this  nerve,  which  is  the  one  most  frequently  affected  by  neuralgia, 
was  obtained  through  the  incision  originated  by  Kocher,  in  order  so 
far  as  possible  to  a^'oid  injury  of  the  fibres  of  the  facial  nerves 
(Fig.  243,  Plate  iii) .  The  incision  began  i/o  cm.  below  the  inner 
end  of  the  lower  margin  of  the  orbit,  ran  obliquely  outwards  and 
downwards  to  the  posterior  lower  edge  of  the  malar  bone.  Reginning 
and  termination  of  the  incision  lay  in  about  the  same  vertical  plane 
as  the  corresponding  points  of  the  supraorbital  incision  (see  p.  213). 
The  length  w^as  about  4  cm.  Avoiding  the  facial  branches,  it  was 
carried  fii"st  only  through  skin  and  fascia  down  to  the  quadrate  muscle 
of  the  u])per  lip,  tlie  fibres  of  which  were  pulled  downwards,  crossing 
the  direction  of  the  incision.  Thereupon  the  upper  branches  of  the 
infraorbital  nerve  (the  inferior  palpebral  and  the  subcutaneous  nasal 
nerves)  came  ijito  view,  since  they  ran  to  the  upper  wound  edge. 
They  were  avoided,  as  shown  on  page  213,  and  left  in  connection  with 
the  trunk,  while  the  peripheral  branches  were  pulled  out  with  the 


218  SURGERY  OF  THE  TRIFACIAL  NERVE 

forceps,  so  that  they  did  not  interfere  with  the  retraction  of  the 
wound  edges. 

After  this  was  accomphshed  the  infraorbital  foramen  was  exposed. 
It  lay  in  the  uppermost  portion  of  the  canine  fossa  about  1  cm.  below 
the  margin  of  the  orbit  and  a  bit  internal  to  its  middle  point.  Since  the 
upper  outer  segment  of  the  foramen  j^ossesses  a  sharp  projecting  edge, 
it  was  readily  found  on  palpating  the  bone  in  the  depths  of  the  wound 
by  running  the  finger  Up  upwards  and  outwards.  The  incision  then 
proceeded  along  the  lower  edge  of  the  orbit  through  the  origin  of  the 
quadrate  muscle  of  the  upper  lip  and  periosteum  down  to  the  bone, 
but  remained  al)ove  tlie  infraoi-liital  foramen.  Then  the  periosteum 
was  stripped  downwards  with  the  raspatory  until  the  branches  of  the 
infraorbital  (pes  anserinus  minor)  Avere  clearly  visible.  This  was 
isolated  from  the  infraorbital  artery  and  a  section  was  shelled  out  by 
blunt  dissection  from  the  surrounding  fat  tissue  and  grasped  pro- 
visionally with  a  hemostat.  We  were  careful  to  leave  behind  no  small 
nerve  branches,  and  therefore  did  not  forget  that  at  times  a  second 
and  less  frequently  even  a  third  opening  was  present,  through  which 
single  minor  branches  of  the  infraorbital  nerve  appeared. 

The  periosteum  of  the  margin  and  floor  of  the  orbit  were  stripped 
backward  as  far  as  possible.  Then  with  a  l)road  retractor  the  orbital 
contents  and  periosteum  were  carefully  lifted  and  one  could  see  the 
nerve,  after  the  slight  bleeding  had  ceased,  as  a  white  stripe  through 
the  translucent  upper  wall  of  the  canal,  and  further  back,  lying  free 
in  tlie  sulcus.  As  the  periosteum  had  not  been  injured,  the  orbital 
fat  did  not  interfere  with  vision;  the  insertion  of  the  inferior  oblique 
muscle  did  not  have  to  be  disturbed,  as  there  was  plenty  of  room. 

The  canal  ran  practically  straight  backwards  and  forwards ;  its  bony 
walls  were  thin  up  to  about  14  cm.  of  the  foramen,  where  the  wide 
inferior  edge  of  the  orbit  formed  its  upper  wall  Avith  a  tliickness  of 
about  1  cm.  At  this  place  a  wedge  of  bone  was  removed  with  a  narrow, 
straight  chisel.  Further  backwards  the  thin  bony  roof  could  be  broken 
away  with  smooth  forceps  (Fig.  24.4,  Plate  4.5).  This  method  when 
possible  is  to  be  preferred,  because  in  this  way  tlie  exceedingly  thin 
upper  wall  of  the  antrum  of  Highmore  cannot  be  injured.  If,  as 
exceptionally  happens,  in  addition  to  the  canal  proper  there  exists  a 
second  smaller  one.  which  may  be  readily  recognized  in  followino- 
back  the  freed-up  nerve  ends,  this  also  must  be  chiseled  open.  Infre- 
quently one  finds  the  upper  wall  of  the  bony  canal  thickened  through- 
out ;  then  the  nerve  cannot  be  seen  through  it  and  one  must  carefidlv 


SECOND  OK   SI  TKUIOll   MAX1LL.\H^     DIVISION  219 

chisel  open  the  entire  canal  from  the  foramen  backwards  without 
opening  the  antrnm.  In  this  case  the  bony  canal  lay  so  {lcej)ly  that  the 
mucous  membrane  of  the  antrum  was  exijosed  here  and  there,  resem- 
bling a  bluish  bladder  (Fig.  244,  Plate  4.5). 

The  entire  contents  of  the  infraorbital  canal  w'as  lifted  up  out  of 
the  bony  channel  on  a  bhmt  hook  as  far  back  as  the  orbital  fissure; 
the  bundle  was  composed  of  the  nerve,  infraorbital  artery  and  vein. 
The  artery  lay  to  the  inner  side  and  below.  This  is  to  be  isolated  only 
if  it  can  be  done  readily,  and  when  one  is  assured  that  no  nerve  fibres 
remain  attached  to  the  artery.  The  nerve  forceps  were  introduced 
as  far  back  as  ])ossible  into  the  orbit,  and,  to  acconi])lish  this  con- 
veniently, fiom  the  outer  side,  and  the  nerve  was  drawn  out  prox- 
imally  by  a  slow%  constant  pull.  Although  the  artery  was  seized 
together  with  a  nerve,  there  was  no  hemorrhage  to  mention.  The 
pci-ipheral  nerve  fibres  were  rolled  up  on  the  clamp  by  a  very  slow 
twisting,  until  the  finest  terminal  branches  came  out  from  cheek,  ujiper 
lip  and  ala  of  nose.  This  caused  this  region  to  be  pulled  up  into  deep 
folds  (Fig.  245,  Plate  45),  inducing  a  complete  anemia,  which,  after 
removal  of  the  nerve  branches  and  the  sudden  disappearance  of  the 
folds,  was  replaced  by  a  strong  hyperemia. 

The  wound  was  sewed  up.  For  two  days  a  thin  drain  was  kept  in 
down  to  the  chiseled  canal.  After  healing  a  small  perceptible  scar 
remained. 

Once  in  a  sixty-six-year-old  man  we  found  no  nerve  in  the  orbit. 
In  following  back  the  nerve  from  the  pes  anserinus  minor  by  chiseling 
the  suri'ounding  bone  it  developed  that  the  nerve  ran  outwards  be- 
tween the  mucous  membrane  of  the  antrum  and  its  bony  wall  to  the 
malar  bone,  and  did  not  enter  the  orbit.  In  this  way  it  reached  the 
spheno-niaxillary  fossa  and  foramen  rotundum,  as  was  demonstrated 
in  twisting  out  the  central  end. 

Til  this  described  manner  one  may  remove  the  infraorbital  nerve 
to  a  point  behind  the  origin  of  the  nu'ddlc  superior  dental,  and  some- 
times the  posterior,  which  usually  comes  off  within  the  inferior  orbital 
fissure,  that  is,  behind  the  orbit.  Freqviently  w^e  are  able  to  demon- 
strate its  inervation  area  to  be  anesthetic  after  the  operation.  On  the 
other  hand,  the  orbital  nerve,  or  even  the  palatine  and  spheno-palatine 
nerve,  can  hardly  be  reached:  to  remove  these  we  must  use  other 
operative  procedures  (Fig.  240). 


220 


SURGERY  OF  THE  TRU^ACIAL  NERVE 


Levator  palpetrae 
supcrioris  muscle 


External  rectu!<  muscle-. 
Lacrimal  gland. 

Inferior  rectus  muncle. 

Ramus  zygomatlco-. 
facialis 


Ramus  alveolaris 
superior  anterior 


N.  lacrimalis 

Ramus  zygomatico- 
temporalis 


N.  opbtbalmicas 
/  N.  trochkaris 
N.  oculomotorius 


N.  intraorbitalis    --N 


Mucous  membrane 
of  antrum 


Rami  dentales 
Buperloies 


Plexus  dentalls  superior 


Rami  glngivales 
superlores 


Casseriaa  ganglion 


.  A'  maxillaris  inferior 
(turued  upward) 


"    y.  waxillaris  saperior 


N.  canalis  pterygoidei  (Vidii) 
N.  sphenopalatinus 


Spbeaopalatine  ganglion 
"Sanjus  alreolaris  superior  posterior 

a.  palatini 


^Processus  pterygoideus 
(external  plate) 


Ramus  alveolaris  superior  mediua 


Gingiva ■ 

Fig.  246 

The  Dental  Branches  of  the  Superior  JIaxillary  Nerve 
S'n.  alveolares  superiores,  the  plexus  dentalis  superior  and  the  rami  dentales  superiores, 
after  removal  of  the  external   plate  of  the  superior   maxilla.     The  zygomatic  nerve  and  its 
anastomosis  with  the  lacrimal  nerve.     Left  side,  seen  from  the  left.      (The  outer  aspect  of 
the  mucous  membrane  lining  the  antrum  is  exposed.) 

(From   Toldt,   Anatomischer  Atlas.     Fig.   1301,  page  862.) 

RESECTION  OF  THE  ORBITAL  NER^^: 

The  liLstory  of  a  forty-two-year-old  man  otherwise  healthy  showed 
as  etiologic  factors  in  a  right  trifacial  neuralgia,  which  had  existed  for 
four  years,  an  injury  of  the  cranium  and  a  moderate  degree  of  alco- 
holism. The  painful  attacks  took  their  origin  in  the  region  of  dis- 
tribution of  the  right  superior  maxillary.  But  they  went  immediately 
over  to  the  right  lingual,  and  could  only  be  temporarily  influenced  by 
various  internal  methods,  by  injection,  and  by  electric  light  baths. 
Recently  the  attacks  had  increased  continually  in  severity,  pain  was 
almost  constant,  so  that  the  patient  was  unable  to  work  and  his  nutri- 
tion sufi^ered  greatly. 

Since,  according  to  our  observation,  the  attacks  limited  themselves 
to  the  distribution  of  the  infraorbital  and  orbital  nerves,  as  well  as  the 
lingual,  it  was  decided  that  peripheral  resection  of  these  nerves  was 
indicated,  as  a  more  serious  operation  appeared  dangerous  on  account 
of  the  patient's  debility. 


Krause-Hevniann-Ehrenfricd- 


Tab.  46. 


Resection  of  the    orl)ital   ner\'e. 


--^ 


rf 


Incision  for  ex- 
posure of  llie 
orbital  nerve 


-mif'f^' 


S^^ 


?\Z-  247.  Incision. 


The  iindividca 

nerve  is  seen 

within   the  orbit 


The  orbital 
nerve  is  Torn 
out,  centrally 


V\g.  243.  Exposure  of  the  trunk  of  the  nerve         Fig.  249.  The  temporal  branch  is  cut  outside  its 
and  its  two  brandies,  the  temporal  and  malar.         foramen,  and  the  trunk  of  the  orbital  is  torn  loose. 


C„.^e*-P^**J\^- 


Orbital  nerve, 
with  its  malat 
branch  intact 


^-x-;«?v 


RebnKin  Company,  New  York. 


Fig.  250.  The  trunk  is  pulled  out  of  orbit  through  canal. 


SECOND  OR  SUPERIOR   .MAXILLARY   DIVISION  221 

All  incision  3  cm.  long  (Fig.  247,  Plate  46)  beginning  at  the  outer 
corner  of  the  eye  was  made  along  the  outer  inferior  edge  of  the  orbit 
through  skin  and  orbicidaris  j)alpebarum  down  to  bone.  The  peri- 
osteum of  the  orbit  was  stripped  up  until  the  undivided  orbital  nerve 
was  visible  above  its  entrance  to  the  zygomatico-orbital  canal  (Fig. 
248,  Plate  46) .  The  slight  liemorrhage  was  controlled  by  gauze.  The 
nerve  was  carefully  exposed  in  the  depths  of  the  orbit  until  its  point 
of  origin  from  the  infraorbital  nerve  was  reached  in  the  inferior  orbital 
fissure.  Then  it  was  seized  with  nerve  forceps  and  pidled  out  prox- 
iinally  (Fig.  249,  Plate  46).  Hereupon  the  periosteum  was  strijjped 
from  the  outer  surface  of  the  malar  bone  until  the  nerve  came  into 
view.  In  this  case  there  were,  as  commonly  happens,  two  openings  in 
the  bone,  and  the  two  branches  were  of  about  equal  size.  As  the 
division  had  taken  place  in  the  bony  canal,  one  of  the  branches  was 
cut  off  close  to  the  foramen  of  the  exit  and  the  other  was  seized  and 
pulled  out  together  with  the  trunk  (Fig.  2.50,  Plate  46).  Finally  the 
peripheral  branches  were  twisted  out  in  the  regular  fashion. 

If  the  division  of  the  nerve  into  its  two  branches,  the  zygomatico- 
temporal and  the  zygomatico-facial,  had  taken  place  in  the  orbit  in- 
stead of,  as  usual,  in  the  zygomatico-orbital  canal,  then  one  w^ould 
have  found  both  branches  under  the  periosteum  of  the  orbit;  and  by 
investigating  further  backward  one  Avould  always  come  upon  the  trunk 
itself. 

In  order  to  remove  the  infraorbital  nerve  in  the  same  patient,  the 
incision  at  the  lower  edge  of  the  orbit  was  lengthened  medially  and 
the  operation  carried  out  as  has  already  been  described. 

The  skin  wound  was  sutured.  In  order  to  prevent  collection  of 
blood  in  the  orbit  a  small  drain  was  left  in  for  two  daj'^s.  Five  days 
after  its  removal  the  wound  was  solid. 

KESECTION  OF  THE  SECOND  DIVISION  AT  THE  FORAMEN  ROTUNDUM 

The  superior  maxillary  nerve  can  be  exposed  at  its  exit  through 
the  foramen  rotundum  only  by  osteoplastic  resection  of  the  zygoma, 
and  dissection  into  the  sjjheno-maxillary  fossa.  This  operation  is  to 
be  considered  only  in  the  infrequent  event  that  nerves  are  affected 
which  on  accoimt  of  their  depth  cannot  be  reached  in  any  other 
manner,  for  instance,  the  palatine  nerves,  or  if  the  pain  from  the 
beginning  has  covered  the  entire  distribution  of  the  second  division. 

A  fifty-nine-year-old  woman  suffered  for  many  years  with  neuralgic 
pains  in  the  left  upper  jaw,  which  had  developed  as  a  sequel  to  root 


222  SURGERY  OF  THE  TRIFACIAL  NERVE 

inflammation  of  the  wisdom  tooth  of  the  same  side.  Several  bony 
operations  were  performed  without  result.  Pain  was  felt  over  the 
entire  infraorbital  distribution,  but  was  particularly  severe  in  the 
region  of  the  posterior  dental,  and  the  palatine  nerves  were  also 
involved,  so  that  resection  behind  their  origin,  that  is  to  say  in  the 
spheno-maxillary  fossa,  was  indicated. 

The  skin  incision  (Fig.  251,  Plate  47)  began  a  finger's  breadth  out- 
side and  below  the  end  of  the  eyebrow,  descended  along  the  posterior 
edge  of  the  frontal  process  of  the  malar  bone  and  then  ran  in  a  flat 
arc,  concave  above,  backwards  and  downwards  to  the  lower  edge  of 
the  zygoma  and  along  this  to  the  anterior  origin  of  the  articular 
tubercle.  Here  the  incision  turned  obliquely  upwards  and  backwards, 
ending  just  above  the  zygoma  in  front  of  the  ear.  In  this  case  the 
temporal  artery  did  not  have  to  be  divided.  The  temporal  fascia  was 
cut  across  along  the  upper  edge  of  the  zygoma,  after  retracting  the 
skin  upwards. 

The  zygoma  was  now  exposed  along  its  medial  surface  with  the 
elevator,  and,  close  to  the  articular  tubercle,  behind  where  the  anterior 
root  of  the  zygoma  comes  away  from  the  temijoral  fossa,  divided  with 
bone-cutting  forceps.  Then  after  pulling  the  skin  and  subcutaneous 
tissue  dowiiM'ards  and  forwards,  so  that  all  of  the  facial  branches 
which  ran  over  the  malar  bone  could  be  avoided,  it  was  chiseled  through 
obliquely  in  front. 

Thereupon  a  Gigli  saw  could  be  pulled  through  under  the  anterior 
origin  of  the  zygoma  Avith  the  aid  of  a  bent  ear  probe,  and  here  it  was 
sawed  through  in  the  line  shown  in  Fig.  255.  If  the  soft  parts  are 
normally  movable,  the  zygoma,  loosened  from  its  connections,  may 
be  pulled  do\\ii  out  of  the  way,  together  with  the  masseter  and  skin, 
with  a  strong  four-jH-onged  retractor.  It  is  important  to  cut  or  chisel 
through  the  zygoma  first  at  the  thin  place  in  front  of  the  articular 
tubercle,  and  then  to  saw  it,  or,  better  still,  to  chisel  it,  through  in 
front  at  the  malar  bone.  If  one  proceeds  in  the  reverse  order,  the 
thin  and  brittle  roots  of  the  zygoma  may  be  splintered  readily,  which 
may  open  up  the  articulation  of  the  jaw.  The  anterior  bony  incision 
must  separate  the  zygoma  entirely  from  the  malar  bone.  It  should 
also  be  made  exactly  from  the  angle  obliquely  downwards  and  for- 
wards to  end  at  the  zygomatic  tubercle,  the  point  of  junction  of  malar 
bone  with  superior  maxilla.  This  technique  gives  plenty  of  room  in 
this  narroAv  operative  field. 

The  approach  to  the  spheno-maxillary  fossa  in  our  patient  was  now 


Krause-Heyiiiann-Fhrenfried.  Tab.  47. 

Resection   of  the  superior  ma.xillarv   iierxe   at  the    foramen   rotunduni. 


Zygomii 

Fig.  251.  Skin  incision;  the  shallow  flap  is  turned  upward. 


Silpffior  inaxilltify  ticrvf 

Infiaorbital  artery 


Palatine  nerves 


/.yi^onia 


h'ig.  252.  With  the  zygoma  turned  downward  and 
the  temporal  nuiscle  retracted  backward,  the  superior 
niaxillary  nerve  can  be  lifted  up  on  a  blunt  hook. 


Zygoma 


Fig.  253.  Tlic  zygoma  is  held  in 

place  by  periosteal  sutures, 
and  a  drainage  tube  is  in.serted. 


■nor  maxUlarv  nerve 


Fig.  254.  The  nerve  is  pulled  oiii  through  the  infraorbital  canal. 


Rc'hni.in  Company,  New  York. 


SECOND  OR  SUI'KUIOR   MAXILLARY  DIVISION 


free;  only  the  anterior  fibres  of  the  temporal  muscle,  which  rim  to  the 
coronoid  process,  had  to  be  divided.  Its  jjowerful  tendon  was  pulled 
backwards  with  a  right-an^le  retractor  (Fig.  2.32,  Plate  47).  Pro- 
ceeding into  the  depths  with  small  sponges  and  a  blunt  elevator,  we 
maintained  a  forward  course  along  the  posterior  surface  of  the 
superior  maxilla,  in  order  in  this  way  to  reach  the  spheno-maxillary 
fossa  below  the  inferior  orbital  lissure.  The  fat  and  the  not-to-be- 
dejjreciated  venous  plexus,  which  made  up  the  contents  of  the  fossa, 
were  pushed  backwards  and  held  with  a  broad,  blunt  retractor. 


Fig.  255 

Incisions  tlivouph  zygoma. 

In  order  to  protect  the  intciiiai  inaxiilarv  artery  from  injury,  it 
was  carefully  i'reed  witli  two  snioolli  foreejjs  from  the  little  tabs  of 
fat ;  it  formed  a  tortuous  curve  and  was  pulled  backwards  with  a 
retractor.  In  Fig.  2.)2.  Plate  -tT,  one  can  see  on  its  branches  the  infra- 
orbital and  the  descending  palatine  arteries,  the  internal  maxillary 
itself  being  hidden  under  the  retractor.  We  now  proceeded  towards 
the  inferior  orbital  fissure,  which  could  be  readily  located  with  a  probe. 


224  SURGERY  OF  THE  TRIFACIAL  NERVE 

Any  fat  which  interfered  with  the  view  in  the  depths  was  removed 
carefully  witli  smooth  forceps. 

Tlie  superior  maxillary  nerve  came  hito  view  at  the  narrowest  por- 
tion of  the  funnel-shaped  wound,  which  was  about  6  cm.  deep,  at  the 
point  where,  emerging  from  the  foramen  rotundum,  it  runs  obliquely 
forwards  and  outwards,  and  a  bit  downwards,  through  the  inferior 
orbital  fissure  to  the  sulcus,  that  is  to  say  the  infraorbital  canal 
(Fig.  252,  Plate  47) .  Here  it  could  be  hooked  up  with  a  small,  sharp 
tenaculimi,  separated  by  blunt  dissection,  and  lifted  away  from  the 
infraorbital  artery  (a  branch  of  the  internal  maxillary  artery),  which 
comes  up  from  without  behind  and  below.  Xow  it  was  seized  firmly 
in  the  nerve  forceps,  freed  up  a  little  further  Avith  the  elevator  under 
a  continuous  gradual  pull,  and  cut  behind  the  forceps  close  to  the 
foramen  rotimdum.  Thus  both  the  superior,  posterior,  dental  and  the 
palatine  nerves  were  removed  at  the  same  time. 

If  the  infraorbital  arteiy  cannot  be  separated  from  the  superior 
maxillary  without  considerable  trouble,  it  is  better  to  divide  it,  so  that 
no  nerve  fibres  remain  behind;  bleeding  ceases  after  temporary 
packing. 

To  prevent  collection  of  blood  a  drain  was  laid  in  the  anterior 
corner  of  the  wound  down  to  the  inferior  orl)ital  fissure  and  the  flap 
containing  bone  and  soft  parts  was  laid  back  in  place.  The  periosteum 
of  the  zygoma  was  drawn  together  with  catgut  sutures  (Fig.  253, 
Plate  47),  and  over  this  the  skin  incision  was  united  carefully. 

The  infraorbital  nerve  was  exposed  in  the  infraorbital  foramen 
in  the  manner  already  described,  and  the  entire  root  of  the  superior 
maxillary  nerve  was  pulled  out  (Fig.  254,  Plate  47).  The  twisting 
out  of  the  peripheral  branches  (Fig.  245,  Plate  45)  ended  the  opera- 
tion. The  drain  was  removed  on  the  third  day,  the  stitches  on  the 
seventh,  and  the  patient  was  discharged  on  the  same  day  free  of  pain. 

VARIATIONS    IX    TECHNIQUE 

In  this  operation  the  exposure  of  the  second  division  could  be  carried 
out  at  the  foramen  rotundum  without  ligature  of  the  internal  max- 
illary artery;  but  usually  this  is  necessary,  as  the  artery  shows  great 
variations  in  its  position  upon  and  between  the  two  bellies  of  the 
external  pterygoid  muscle  as  well  as  in  its  branches,  in  which  case 
it  is  double  tied  and  divided  between  the  ligatures.  Ordinarily  hemor- 
rhage after  ligature  and  division  of  the  internal  maxillary  is  slight, 
and  at  times  it  is  entirely  absent,  which  shortens  the  time  necessary 


SECOND  OR  SrPERIOR  MAXITJ,ARV  DIMSIOX  225 

for  the  operation,  but  there  is  sometimes  severe  hemorrhage  from  the 
ptery<>oi(l  venous  plexus,  which  is  very  disturbing  in  so  narrow  a  field ; 
nothing  further  can  be  done  than  to  pack  the  wound  with  gauze  and 
compress  it  tightly  for  a  while. 

Resection  of  the  temporal  process  of  the  lower  jaw  is  not  necessary 
for  exposure  of  the  second  division. 

The  avenue  of  approach  to  the  de{)ths  of  the  spheno-maxillary 
fossa  may  be  encroached  upon  if  the  maxillary  tuberosity  is  unusually 
well  developed.  Kronlein  in  such  a  case  chiseled  away  the  bony 
process,  opening  the  antrum;  in  this  patient  a  fistula  of  the  antrum 
persisted.  We  have  tried  another  method  in  several  cases.  The  pala- 
tine nerves  (Fig.  246),  which  run  down  from  the  spheno-palatine 
ganglion,  just  before  they  enter  the  pterygo-palatine  canal,  lie  be- 
tw'een  the  posterior  surface  of  the  superior  maxilla  and  the  pterygoid 
process,  more  superficial  than  farther  up  toward  the  ganglion.  There 
one  may  find  them  more  readily,  and  if  one  lifts  them  up  carefully 
on  a  hook,  one  can  without  difficulty  follow  them  up  and  reach  the 
spheno-jjalatine  ganglion  and  the  superior  maxillary  nerve. 

If  the  approach  to  the  spheno-maxillary  fossa  is  particularly 
narrow^  one  may  introduce  a  small  right-angled  hook  in  front  of  the 
readily  palpable  spine  of  the  infra-temporal  crest  of  the  sj)henoid 
down  to  the  median  boundary  of  the  inferior  orbital  fissvn'e,  and  pidl 
out  its  entire  content,  consisting  of  fat,  infraorbital  artery  and 
superior  maxillary  nerve.  In  this  way  the  nerve  may  readily  be 
isolated  and  resected. 

The  infraorbital  artery  may  rarely  pass  through  the  middle  of  the 
superior  maxillary  nerve,  so  that  the  nerve  appears  to  be  split  into 
two  portions. 

I>exer  shortens  the  described  incision  in  front  and  behind  and  carries 
it  only  along  the  upper  edge  of  the  zygoma.  This  method  is  good 
for  experienced  operators  and  for  resection  of  the  third  division  alone 
at  the  foramen  ovale.  For  the  second  division  it  is  not  to  l)e  recom- 
mended. The  narrow  approach  to  the  deep  wound  obstructs  the  view, 
])articularly  if  bleeding  occurs  from  the  pterygoid  plexus.  Otherwise 
Lexer's  technique  is  not  very  different  from  the  one  we  have  de- 
scribed. 

Temporary  resection  of  the  zygoma  to  reach  the  second  division 
at  the  foramen  rotundum  was  first  carried  out  by  Liicke;  but  since 
his  incision  divides  the  branches  of  the  facial  nerve,  we  do  not  emjjloy 
it.    The  same  is  true  of  the  following  modification  of  the  method  of 


226 


Gasserlan  ganglion 
N.  trochlearls  \ 


SURGERY  OF  THE  TRIFACIAL  NERVE 

Tentorium  cerebelH 
N.  tentoiii 


N.  opbtbalmicttB 
Superior  oriltal  flaau^e 


iiiddte  mcnwqefil   artery,  ivith^he 
recurrent  spiitrms  nerve 
JV.  auriculotewporalis 

Nn.  meatus  audltorll  externl 
Cartilaginous  external 
auditory  meatus 

Rranclies  of  the, 
facial  nerve 


pteriigo-maxitlarU 

fissure 


internal  maTillarif 
artery 


Internal  pterggoid 
muscle 


Anastomotic  branches 
__    with  facial  nerve 


Posterior  facial  vein 

^  Iingualia 

Rami  isthml  faucium 
.^^    External  maxillary  artery 

!^    X      Radix  s.vmpathicn 

sanglii  submaxllTaris 


N.  sublingualis 

Ceniogloseiis  muscle 

Geniohyoid  muscle 

Mylohyoid  muscle 
(turned  down) 


Sublingual  gland 

Branches  In   the   mucous  membrane 
or  the  floor  of  the  mouth 


-      Submaxillary  gland 
'    Ramisuhmaiillares 
Submaxillary  duct 
Submaxillary  ganglion 
Rami  communicantes  cum  n.  Ilnguall 


N,  hypoglossus 


of 


Fiu.  2JG 


The  Third  oh  Inferior  Maxillary  Division  of  the  Tkifacial.  Its  Motor  Branches  and 
THE  Inferior  Dental  Nerve  are  Cut  Away  Close  to  the  Base  of  the  Skull 
(On  tlic  left  side  of  the  liead  an  oblique  incision  lias  been  carried  down  in  front  of 
the  ear,  throuf;!!  tlie  parotid  f,'land.  the  left  liaif  of  lower  jaw  removed,  and  a  wedge  of 
bone  removed  from  base  of  skull  l)etween  malar  bone  and  external  meatus,  with  the  apex 
at  foramen  ovale.  The  posterior  portion  of  the  parotid  has  been  turned  back,  with  the 
skin  llap.) 

(From   Toldt,   .\natomischer  Atlas,   Fig.   1304,   page  804.) 


Krause-Heymann-Ehrenfried. 


Tab.  48. 


Resection  of  the  linoual   nerve. 


Sub/ ill  gnat 


y 


Fig.  257.  Incision  through  mucous  membrane. 


Lingual  nerve 


Fig.  258.  Exposure  of  lingual  nerve. 


Rebman  Company,  \'e«  ^■ork. 


THIRD  OR  INFERIOR  MAXILLARY  DIVISION  227 

Lessen  and  Braun:  The  riglit-an<)le  incision  begins  1  cm.  above  the 
outer  canthus,  2  to  3  mm.  from  tlie  outer  edge  of  the  orbit,  and  runs 
obhquely  forwards  and  downwards  to  the  neighborhood  of  the  third 
upper  mohu-  to  tlic  point  where  the  zygomatic  process  of  the  ujiper 
jaw  can  be  felt  as  a  projecting  angle.  The  incision  is  carried  through 
periosteum  down  to  the  zygoma;  this  is  freed  of  periosteum  on  its 
medial  surface  and  is  divided  in  the  line  of  the  incision  with  a  Gigli 
saw.  The  second  leg  of  the  right  angle  runs  from  the  upper  end 
of  the  first  incision  backwards  to  the  zygomatic  process  of  the  tem- 
poral bone,  and  cutting  skin  and  temporal  fascia.  The  zygoma  is 
freed  of  periosteum  behind  in  front  of  the  articular  tubercle  and  di- 
vided, and  the  flap,  which  consists  of  skin,  zygoma  and  masseter 
muscle,  is  turned  downwards  on  its  base  and  is  held  here  with  rake 
retractors. 

This  technique  is  to  be  recommended  only  if  the  previously  de- 
scribed procedure  is  made  difficult  by  scars  resulting  from  previous 
operations. 


THIRD  OR  IXFERIOR  MAXILLARY  DIVISION 

If  the  neuralgic  pains  limit  themselves  definitely  and  permanently 
to  one  branch,  resection  of  this  branch  is  indicated.  We  will  discuss 
first  the  techm"que  of  operation  on  the  single  branches. 

RESECTION  OF  THE  LINGUAL  NER^-E 

After  the  lingual  nerve  has  entered  the  base  of  the  tongue  between 
the  ramus  of  the  lower  jaw  and  the  palato-glottidean  fold,  it  lies  in 
the  ncighl)orhood  of  the  three  last  molar  teeth  just  under  the  mucous 
membrane  and  exactly  at  the  point  of  transition  from  the  side  of  the 
tongue  to  the  floor  of  the  mouth.  One  may  even  see  the  nerve  through 
the  membrane. 

In  this  case  the  ])atient  was  the  same  one  mentioned  on  page  221. 
The  mouth  was  held  wide  open,  the  cheek  was  reti-acted  outward,  the 
tongue  was  drawn  out  and  upward  to  the  left  with  tongue  forceps, 
so  that  the  posterior  section  of  the  tongue  lay  exposed  on  the  right 
side.  Then  at  the  place  described  above,  in  the  region  of  the  last 
molar,  at  the  anterior  pillar  of  the  fauces,  the  mucous  membrane  was 
incised  not  too  close  to  the  tongue,  biit  at  the  point  of  junction  with 
the  floor  of  the  mouth  (Fig.  2.37,  Plate  48) .    In  this  patient  the  nerve 


SURGERY  OF  THE  TRIFACIAL  NERVE 

was  covered  by  the  upper  edge  of  the  submaxillary  gland,  but  after 
excision  of  a  small  piece  of  the  upper  segment  of  the  gland  it  could 
be  readily  isolated  and  twisted  out  peripherally  in  the  typical  fashion 
(Fig.  2;58,  Plate  48).  Proximally  it  was  pulled  out  as  far  as  possible 
and  cut.     The  small  wound  was  sutured  with  interrupted  catgut. 

After  ten  days  the  mucous  membrane  of  the  floor  of  the  mouth  had 
healed  under  the  employment  of  hydrogen  dioxid.  The  tongue  was 
freely  movable  in  all  directions.  The  patient,  in  whom  at  the  same 
sitting  the  orbital  and  infraorbital  nerves  had  been  resected,  remained 
three  weeks  in  the  hospital,  and  was  then  discharged  without  pain,  in 
good  state  of  nutrition  and  able  to  work. 

RESECTION  OF  THE  AURICULG-TEJIPOKAL  NERVE 

A  sixty-eight-year-old  woman  had  suffered  for  four  years  with 
severe  attacks  of  pain  in  the  right  side  of  the  face.  The  attacks  at 
first  came  on  daily,  then  as  often  as  every  horn-,  and  as  a  rule  lasted 
several  minutes.  Attempts  at  eating  or  talking  induced  attacks,  so 
that  the  patient  developed  a  distressing  condition  as  regards  nourish- 
ment. For  no  single  week  had  the  patient  been  without  pain  in  the 
Jast  fiA-e  months. 

According  to  her  description,  the  attacks  began  in  two  centres, 
sometimes  simultaneously  and  sometimes  following  each  other  closely. 
At  times  it  was  the  outer  lower  edge  of  the  orbit  from  which  the  pains 
radiated  hito  the  region  of  the  right  upper  jaw,  sometimes  a  point 
just  in  front  of  the  right  tragus,  from  wliich  tlie  pains  radiated  some- 
what forward  and  uj^ward  to  the  region  of  the  temple.  Since  the  pains, 
apart  from  the  infraorbital,  definitely  had  their  situation  in  the 
auriculo-temporal  region,  and  operative  procedure  had  to  be  limited 
to  the  utmost,  on  account  of  the  great  weakness  and  advanced  arterio- 
sclerosis, the  auricido-temporal  as  well  as  the  infraorbital  was  resected. 

The  terminal  branch  of  this  nerve,  the  superficial  temporal,  which 
sometimes  divides  into  two  branches,  may  be  reached  by  an  insignifi- 
cant procedure  at  the  point  where  it  emerges  from  the  upper  angle  of 
the  parotid  and  together  with  the  superficial  temporal  artery  runs 
upwards  in  the  loose  connective  tissue  in  front  of  the  auricle  to  the 
temple  (see  Fig.  2,^0).  JMore  centrally  the  nerve  is  covered  by  the 
articular  process  of  the  lower  jaw.  and  here  it  can  only  be  reached  by 
an  operation  which  exposes  the  base  of  the  skull  from  below. 

A  vertical  incision  (Fig.  2.59,  Plate  40)  was  made  directly  in  front 
of  the  tragus,  beginning  at  the  upper  edge  of  the  zygoma  and  running 


Krause-Heymann-Ehren  fried. 


Tab.  49. 


Resection  of  the  auriculo-tcmpoi-al   ncr\-e. 


Anriaito-temporal  nerve  and  its 
accompanying  t'essf/s 


Fig.  259.  Incision  for  exposure  of  the  anricnlo-teniponil  nerve. 


Fig.  260.  Nerve  and  vessels  exposed. 


Superficial 
temporal  nerve 


Superficial 
temporal  nerve 


Fig.  261.  Isolation  of  the  superficial  temporal  nerve. 


Fig.  262.  Vessels  are  double  tied  and  divided ; 
the  nerve  is  seized  and  pulled  out  centrally. 


Ri'bni.in  Conil).iny,  New  ^■ork. 


THIRD  OR  I\FF:RI0R  MAXILLARY  DIVISION  229 

upward  about  '2y->  cm.  In  this  region  of  the  face  it  is  allowable  to 
make  a  vertical  incision,  because  from  the  lower  edge  of  the  zvyoma 
upwards  there  are  no  fibres  of  the  facial  nerve  of  any  significance. 
The  incision  sei)arated  skin  and  fascia  down  to  the  temporal  fascia, 
but  this  does  not  have  to  be  incised.  Upon  this  lay  the  bundle  con- 
sisting of  temporal  artery  and  the  accompanying  veins,  and  behind 
toward  the  ear  the  superficial  temporal  nerve,  which  sends  many 
branches  to  the  concha  (Fig.  260,  Plate  -lO).  In  this  case  two  could 
be  isolated  and  pulled  out  with  the  forceps  (Fig.  261,  Plate  49). 
Thereupon  artery  and  vein  were  ligated  as  far  above  and  below  as 
possible,  and  excised,  so  that  no  nerve  fibres  might  remain  behind 
in  connection  with  them.  The  trunk  of  the  auriculo-temporal  nerve 
could  be  followed  until  it  disappeared  behind  the  head  of  the  man- 
dible; it  was  seized  in  the  depths  and  slowly  twisted  out  (Fig.  262, 
Plate  49). 

The  wound  was  closed  by  clamps  without  drainage.  The  second 
day  after  operation  the  patient  got  out  of  bed;  the  wound  healed  per 
primam.     Xo  further  attacks  occurred. 

The  l)ranches  of  the  auriculo-temporal  nerve  running  to  the  external 
meatus  were  not  met  in  this  procedure.  They  ordinarily  leave  the 
trunk  of  the  auriculo-temporal  nerve  at  the  medial  or  posterior  side 
of  the  articular  process.  This  nerve,  rising  by  two  roots  from  the 
third  di\ision,  close  under  the  foramen  ovale,  and  enclosing  the  middle 
meningeal  artery,  passes  at  the  medial  side  of  the  neck  of  the  articular 
process  backwards  in  a  horizontal  direction  over  the  internal  maxillary 
artery  and  comes  to  the  surface  behind  it  (Fig.  2.56). 

RESECTION    OF   THE   INFERIOR    DENTAL   AND    LINGUAL   NERAT<:S 

Ordinarily  for  exposure  of  the  inferior  dental  and  the  lingual  nerves 
we  employ  a  modification  of  the  technique  of  ^Mikulicz. 

In  a  fifty-year-old  patient  who  suffered  from  neiu*algia  of  the  in- 
ferioi-  dental  nerve,  repeated  injections  of  alcohol  were  made  into  the 
trunk  of  the  inferior  maxillary  at  the  foramen  ovale.  The  first  time 
the  anesthetic  effect  lasted  four  months,  the  second,  six  weeks.  As 
further  injections  were  without  result,  the  nerve  was  exposed  in  the 
inferior  dental  canal  from  the  mental  nerve  up  and  resected.  But 
after  six  months  the  pains  returned  and  spread  to  involve  the  tongue. 
The  j)atient  coming  to  us,  we  carried  out  resection  of  the  nerve  in  the 
following  manner  (Fig.  263)  : 


230  SURGERY  OF  THE  TRIFACIAL  NERVE 

IV.  auprtorbitalla  ^ 


BtuauB  tt'oataltB 


Kamus  lygomaticotacM'^  External  pienjooid  muscle, 
upper  and  lower  heads 

Temporal  muxcle 

N.  temporalis  profundus 
aoierlor 


I  N.  temporalis 
r     profundus 
posterior 


Branches  of  the  Infia-    i« 
trochlear  nerve 


ff.  Infraorbl' 
talis 


External  nasal 
tranches  of  the 
ethmoidal 
nerve 


External  nasal 
branches  of  the 
Infraorbital 
nerve 


Rami  lablales 
superlores 


Masseter 

muscle 


Jnicrnal  pterygoli 
muscle 


Inferior  dental 
nerre 


Buccal  glands 


Mucous  tnembrane 
of  lower  lip 

Buccinator  muscle 


N.  mylohyoideus 
N.  lingualls 


Inferior  dental  and  gingival 
branches  for  the  front  teeth 


Inferior  dent&l 
nerve 

:,;jii»'  v    Inferior  dental  plexus 

Inferior  dental  branches 
N.  meatatlis 
Fig.  2C3 


The  Inferior  Dental  Nerve,  Its  Coitrse  Tiikoioh  the  Canal  in  the  Lower  Jaw,  Its 

Branches,    With    the    Inferior    Dental    Plexus,    and    Its   Terminal   Branch,   the 

Mental  Nerve.    The  Biccinator  Nerve 

Of  the  motor  branches  of  the  third  division  the  deep  anterior  and  posterior  temporal 
nerves,  and  the  masseteric.  The  zygomaticofacial  branch  of  the  zygomatic,  the  superior  labial 
branches,  and  the  skm  nerves  of  the  external  nose.  The  branches  of  the  first  division  to  the 
region  of  the  forehead. 

(After  removal  of  the  zygoma,  the  proximal  portion  of  the  ramus  of  lower  jaw,  and 
the  anterior  plate  of  the  body  of  tlie  jaw.  The  lower  portion  of  the  temporal  muscle  has 
been  removed,  to  expose  the  deep  temporal  nerves.) 

(From  Toldt.  Anatomischer  Atlas,  7th  edition.   1911,  Fig.   1305,  page  8G5.) 


Krause-Heyniann-Elirenfried. 


Tab.  50. 


Resection   of  the   inferior  dental   and   lingual  nerves. 


Mosseter  muscle 


Parotid 
Shimi 


Fig.  264.  Incision,  throngh  skin  and  niasseter. 


Inferior  dental  nerve 


Line  for 

chiseling  across 

the  ramus  of 

the  jaw 


Inferior  dental 
artery 


Lingual 
nerve 


Fig.  265.  Exposure  of  the  ascending  ramus  of  the  jaw, 
and  chiseling  open  of  the  inferior  dental  canal. 


Fig.  266.  The  divided  ends  of  the  ramus  are  drawn 
apart,  showing  the  nerves  and  vessels. 


Internal  pterygoid  muscle 


Inferior  maxillary  nerve 
Lingual  nerve 
Inferior  dental  nerve 


Fig.  267.  Twisting  out  the  inferior  denial  nerve,  after  its 
two    terminal   brandies  iiave   already   been   pulled    out. 


Rebman  Company,  New  \'ork. 


THIRD  OR  INH^HIOR  :\IAXILLARY  DIVISION  231 

The  head  was  laid  upon  one  side,  the  affected  side  up,  and  was  well 
lighted.  The  incision  throiifvh  skin  and  snbcutaneons  tissne  began 
1  cm.  behind  and  niider  the  lobe  of  the  ear,  curved  around  this  (Fig. 
264,  Plate  .50),  and  jjroceeded  horizontally  forward  to  tlic  anterior 
edge  of  the  ramus  of  the  jaw.  Its  length  was  6  cm.  The  incision 
running  horizontal  and  parallel  to  the  fibres  of  the  facial  nerve,  their 
injury  could  be  entirelj*  avoided  provided  the  small  tibres  which  were 
met  in  the  incision  were  avoided  and  retracted  to  one  side.  In  the 
posterior  corner  of  the  wound  the  parotid  gland  came  into  view.  Its 
u])permost  section  was  exposed  and  carried  backwards  and  do^vn- 
wards.  The  gland  was  accordingly  not  injured,  nor  was  the  duct  of 
Steno,  which  ran  below  the  incision. 

The  exposed  masseter  was  divided  transversely  with  a  knife  and 
the  periosteum  of  the  ramus  of  the  jaw  was  divided  in  the  same  line. 
The  periosteum  was  stripped  back  to  expose  bone.  As  a  resection 
had  already  been  performed  on  the  inferior  dental  nerve,  we  had  to 
look  for  adhesions  in  the  inferior  dental  canal,  and  so  this  nerve  was 
first  exposed. 

The  internal  orifice  of  the  inferior  dental  canal  lies  about  3  cm. 
above  the  corner  of  the  jaw  and  about  equidistant  from  the  anterior 
and  posterior  edges  of  the  ramus.  In  front  the  opening  is  somewhat 
covered  by  a  projecting  bony  process,  the  lingula.  The  canal  itself 
runs  through  the  bone  somewhat  closer  to  the  medial  surface  than 
to  the  external.  Accordingly,  in  the  middle  of  the  ramus  an  oval- 
shaped  area  of  bone  was  chiseled  out  to  expose  the  canal  (Fig.  265, 
Plate  50),  and  it  was  extended  upward  until  it  reached  the  internal 
orifice.  The  artery  lay  above  to  the  posterior  side  of  the  nerve,  and 
further  down  to  the  medial  side. 

If  no  operation  had  been  performed  previously  in  the  region  of 
the  inferior  dental,  this  exposure  woidd  not  have  been  necessary;  in 
chiseling  the  lower  jaw  through  transversely,  the  nerve  may  easily  be 
protected  from  the  injury,  and  it  can  be  pulled  out  in  its  entire  extent 
as  far  as  the  mental  foramen.  One  may  obtain  the  same  result  if  with 
the  Gigli  saw  he  ahnost  completely  divides  the  ranuis,  and  uses  a  chisel 
to  complete  the  cut. 

After  exposure  of  the  nerve  in  this  case  the  ramus  of  the  jaw  was 
freed  from  soft  parts  on  the  medial  surface  with  a  bent  elevator  and 
chiseled  through  horizontally  1  cm.  below  the  sigmoid  notch.  The 
upper  portion  could  be  brought  ahnost  horizontally  upward  and  out- 


232  SURGERY  OF  THE  TRIFACIAL  NERVE 

ward,  the  bodj^  of  the  jaw  was  pulled  downward  and  forward  (Fig. 
266,  Plate  50). 

The  fatty  bodj^  of  the  cheek  (corpus  adiposuni  malje)  lying  along 
the  anterior  edge  of  the  masseter  does  not  have  to  be  removed  in  this 
operation,  but  the  deeper  fat  layer,  which  contains  the  nerves  and 
vessels  ujion  the  external  aspect  of  the  internal  pterygoid  muscle  as 
far  up  as  the  external  pterygoid,  does.  After  luxation  of  the  upper 
jjortion  of  the  lower  jaw,  the  inferior  dental  nerve  ordinarily  can  be 
pulled  out  of  the  canal  at  the  lingula. 

In  the  funnel-shaped  space  between  the  ramus  of  the  jaw,  the  in- 
ternal pterygoid  muscle  and  the  parotid,  the  apex  of  which  was  di- 
rected toward  the  foramen  ovale,  upon  the  f reed-up  internal  pterygoid 
was  found  the  inferior  alveolar  nerve,  which  had  been  divided  at  the 
previous  operation,  and,  medially,  the  lingual  nerve  (Fig.  266, 
Plate  50).  Along  these  nerves  we  proceeded  upwards  to  the  lower 
edge  of  the  external  pterygoid  and  met  the  muscle  branches.  The 
chorda  tympani  nerve  was  rendered  visible  by  careful  blunt  dissection 
with  smooth  forceps  (see  Fig.  236)  as  well  as  the  internal  maxillary 
artery  as  it  bridged  over  the  two  large  nerves  (inferior  dental  and 
lingual).  This  artery,  however,  did  not  have  to  be  tied,  as  it  could 
be  readily  displaced  forward  and  held  under  a  blunt  retractor. 

The  common  trunk  of  the  lingual  and  the  inferior  dental  nerves 
could  be  exposed  slightly  higher  still.  By  careful  blunt  dissection  the 
inferior  maxillary  could  be  freed  from  the  surrounding  soft  parts  for 
a  considerable  distance  toward  the  base  of  the  skull.  From  the  ovale 
we  were  separated  only  by  the  external  jjterygoid  muscle;  therefore 
the  origin  of  the  auriculo-temporal  nerve  did  not  come  to  view.  The 
inferior  maxillary  nerve  was  seized  in  the  nerve  clamp  as  high  up  as 
possible,  under  careful  isolation  (Fig.  267,  Plate  50),  taking  par- 
ticular care,  on  account  of  the  dej^th  of  the  wound,  that  only  the  nerve 
was  caught  in  the  clamp.  The  root  was  then  pulled  free  from  the 
base  of  the  skull  by  a  pull  A\'hich  at  first  was  very  weak  and  then  in- 
creased in  strength  until  it  became  quite  powerful.  If  this  had  not 
been  successful,  the  nerve  coidd  have  been  pulled  down  at  least  1  cm. 
and  then  divided  with  scissors  high  up  above  the  origin  of  the 
branches.  Finally  the  lingual  nerve  with  its  peripheral  branches  was 
twisted  out  in  the  forceps ;  from  the  inferior  dental  nerve  also,  in  spite 
of  the  antecedent  resection,  a  considerable  segment  could  be  obtained. 

After  completion  of  the  operation,  the  upper  bony  fragment  was 
replaced;  three  muscle-periosteum  stitches  sufficed  to  hold  it  in  posi- 


THIRD  OR  I\FF,RI()1{  .MAXILLARY  DIVISION'  233 

tion.  Bone  sutures  are  not  necessary  in  this  operation.  At  the  pos- 
tei-ior  corner  of  the  wound  a  drain  was  kept  in  for  three  days,  the  skin 
Avound  being  sewed  up.  One  week  after  operation,  the  patient  was 
discharged  without  pain.  This  favorable  residt  persisted  for  two 
years:  at  the  same  time  it  was  demonstrated  that  there  was  no  pa- 
resis in  the  (hstrihution  of  tlie  facial  nerve  or  any  limitation  of  the 
motion  in  the  healed  lower  jaw. 

In  the  metliod  described  for  dividing  the  lower  jaw  injiny  of  the 
mucous  memhrane  of  the  mouth  is  avoided  because  the  internal  ptery- 
goid muscle  lies  for  the  most  part  external  to  it.  The  incision  de- 
scribed r>ins  aliove  the  branching  of  the  facial,  and  near  the  division 
of  the  internal  maxillary  into  inferior  dental  and  lingual.  Also  the 
parotid  is  encountered  only  in  its  uppermost  section  or  not  at  all,  and 
can  be  shoved  to  one  side.  JNIoreover  in  chiseling  through  the  ramus 
of  the  jaw,  one  does  not  have  to  approach  closely  to  the  sigmoid  notch ; 
sometimes  in  old  people  the  bone  may  splinter  through  into  the  notch. 

If  the  internal  maxillary  artery  ol)structs  the  view,  it  can  be  tied 
and  divided  between  the  ligatures,  but  we  have  found  this  only  ex- 
ceptionallj'  necessary.  Usually  it  is  preferable  first  to  twist  out  the 
inferior  dental  nerve  and  then  the  lingual  periplierally;  then  keep- 
ing the  long  nerve  ends  under  tension  to  proceed  upwards  along 
them.  In  order  to  follow  the  nerve  centrally  to  the  origin  of  the 
auriculo-temporal  and  the  foramen  ovale  it  is  necessary  to  pull  the 
external  pterygoid  nniscle  strongly  forward  and  upward  after  the 
fibres  which  run  from  befoi-e  backwards  across  the  nerves  have  been 
torn  so  far  as  necessary'  with  forceps  or  elevator.  One  also  finds  the 
auriculo-temporal  nerve  behind  the  lingual  and  inferior  dental,  form- 
ing a  loop  about  the  middle  meningeal  artery  (see  Fig.  2.)6) .  In  this 
way  it  is  possible  to  follow  all  the  branches  of  the  third  division  to  the 
base  of  the  skull.  In  tearing  out  the  entire  third  division  from  the 
foramen  o\'ale  by  the  method  described,  one  occasionally  sees  at- 
tached to  the  upper  end  of  the  white  nerve  a  grayish  red  mass  in 
which  on  microscopic  examination  ganglion  cells  are  to  be  found;  in 
this  case  extirpation  has  been  can-ied  into  the  Gasserian  ganglion. 

MODIFICATIONS  IN  TECHNIQUE 

The  technique  described  resembles  closely  that  of  Mikulicz  who 
originated  the  temporal  extra-l)uccal  resection  of  the  lower  jaw.  His 
incision  runs  from  the  mastoid  along  the  anterior  edge  of  the  sterno- 
mastoid  to  the  level  of  the  hyoid  and  curves  forward  and  upward  to 


234  SURGERY  OF  THE  TRIFACIAL  NERVE 

the  lower  edge  of  the  jaw  which  it  mets  at  the  anterior  boundary  of 
the  masseter  muscle.  Here  the  incision  goes  down  to  bone;  the  peri- 
osteum is  stripped  up  all  around,  just  at  the  toothless  portion  of  the 
body  of  the  jaw  behind  the  wisdom  tooth,  but  the  oral  cavity  is  not 
ojiened.  Ordinarily  this  is  successful;  at  times,  however,  the  mucous 
membrane  is  torn  and  necrosis  of  the  sawed  surface  results,  particu- 
larly in  old  persons,  as  even  the  most  exact  suture  of  mucous  mem- 
brane does  not  always  hold  securely. 

Mikulicz  divides  the  jaw  transverselj'^  at  the  anterior  insertion  of 
the  masseter  with  the  Gigli  saw,  and  separates  the  insertion  of  the 
internal  pterygoid  from  the  bone  Avith  scissors.  After  the  ranms  of 
the  jaw  is  luxated  as  far  outward  as  possible,  the  procedure  is  con- 
tinued as  given  above.  Finally  the  bone  is  sewed  together  with  alumi- 
num bronze  wire,  which  is  unnecessary  in  the  technique  we  have  given. 

RESECTIOX  OF  THE  THIRD  DIVISION   AT  THE  FORAilEX   OVALE 

In  a  forty-six-year-old  patient  the  inferior  dental  and  lingual  nerves 
were  removed  on  account  of  right-sided  neuralgia.  A  severe  recur- 
rence made  resection  of  the  third  division  at  the  foramen  ovale  neces- 
sary. The  incision  (Fig.  269,  Plate  .51 ) ,  in  order  to  avoid  the  branches 
of  the  facial,  began  near  the  outer  end  of  the  eyebrow  and  proceeded 
along  the  posterior  edge  of  the  frontal  process  of  the  malar  bone  and 
the  lower  edge  of  the  zygoma.  At  the  posterior  end  it  ran  upwards 
and  backwards  obliquely  in  front  of  the  ear,  down  under  the  bone. 
Temporal  artery  and  veins  were  divided  and  ligated.  In  front  a  few 
fibres  of  the  orbicularis  palpebrarum  were  divided  and  the  skin  to- 
gether with  the  facial  branches  was  pulled  down  with  retractors. 

After  the  strong  temporal  fascia  had  been  separated  along  the  up- 
per edge  of  the  zygoma,  the  zygoma  was  chiseled  through  according 
to  the  method  of  Liicke  (see  pp.  222,  235)  first  behind,  in  front  of  the 
articular  tubercle,  then  in  front  in  the  oblique  line  already  described. 
The  skin  flap  was  turned  upward  and  the  zygoma  in  connection  ^vith 
skin,  the  parotido-masseteric  fascia,  and  masseter  muscle  were  dis- 
located downward,  so  that  after  removal  of  the  covering  layer  of  fat 
the  temporal  muscle  with  its  insertion  into  the  coronoid  process  of 
the  lower  jaw  was  exposed  (Fig.  270,  Plate  51). 

This  was  freed  up  from  muscle,  the  masseter  without  and  the  in- 
ternal pterygoid  within,  by  an  elevator  and  cut  off  at  its  base  with 
bone-cutting  forceps  exactly  in  the  line  which  runs  from  the  deepest 
portion  of  the  sigmoid  notch  obliquely  downward  and  forward  to 


Krausc-Heyniann-Ehrenfried. 


Tab.  51. 


Resection   of  the   inferior  ma.xillary  ner\c  at  the  ft)ramen   ovale. 


Zygoma/ 

Fig.  269.  The  incision  is  made,  and  the  shallow  flap  tnrned  upwards. 


Temporal  miiar/ff 


Coronoid  process 
of  lower  jaw 


y.ygonui 


Internal  max- 
illary arterv  . 


External  ptery^ot'd  muscle 

I 


Fig.  270.  The  zygoma   is  tnrned  down,   showing 
the  line  of  incision  of  the  temporal  muscle. 


Fig.  271.  The  lower  portion  of  the  temporal  muscle 
together  with  the  coronoid  process  have  been  excised. 


I  xtenial  pteryaoUl  muscle 


Zygoma 


Inferior  nerve 


Fig.  272.   The   inferior   dental   nerve   is   lifted    on   a   director 
and  seized  with  a  nerve  clamp  just  helow  the  foramen  ovale. 


ibman  Company,  New  York 


THIRD  OR  INFERIOR  MAXILLARY  DIVISION 


235 


the  internal  oblique  line  (Fig.  268).  The  loosened  up  process  was 
turned  upward  together  with  the  attached  temporal  tendon  and  was 
cut  away  with  the  lower  portion  of  the  temporal  muscle.  This  ex- 
posed the  infratenijioral  fossa  and  at  the  same  time  the  external  pterj'- 
goid  muscle  (Fig.  271,  Plate  51).  Between  its  two  points  of  origin 
ran  the  internal  maxillaiy  artery,  which  sometimes  also  lies  upon  the 
muscle. 


Fig.  208 
Incisions  tlivonj;li  zj'soina  and  coronnid  prnccss  of  jaw. 

In  exposing  the  external  pterygoid  muscle  a  large  vein  came  into 
view  whicli  had  to  be  double-tied  and  divided.  The  muscle  was  pulled 
ujjward  and  divided,  and  by  blunt  dissection  with  anatomical  forceps 
tlie  internal  maxillary  was  fiu-ther  exposed,  double-tied  and  divided. 
Then  we  proceeded  down  to  the  external  plate  of  the  pterygoid  {pro- 
cess, cleaned  it  up  with  a  ras])at()i-y  and  gauze,  and  finally  reached  the 
posterior  edge  of  the  pterygoid  just  where  its  roots  went  over  into  the 
base  of  the  skull  at  the  foramen  ovale.  This  occasioned  strong  venous 
bleeding  from  the  jjterygoid  plexus.    This  could  not  be  controlled  bj' 


^'36  SURGERY  OF  THE  TRIFACIAL  NERVE 

compression  with  gauze  but  it  ceased  under  pressure  with  sponges 
whicli  had  been  dipped  in  ach-enahn  solution.  The  large  nerve  trunk 
coming  out  was  exposed  by  blunt  dissection  (Fig.  272,  Plate  51), 
seized  in  the  nerve  clamp  and  torn  out  from  the  cranium  according  to 
the  method  described  on  page  224..  At  the  same  time  the  otic  ganglion 
was  removed. 

A  drain  was  laid  in  the  depths  down  to  the  foramen  ovale  and  car- 
ried out  above  the  zygoma.  A  few  catgut  sutures  fastened  the  zygoma 
to  its  original  site  (see  Fig.  253,  Plate  47)  and  the  skin  wound  was 
sewed  up.  The  drain  was  removed  in  three  days  and  six  days  later 
the  patient  was  discharged  without  pain. 

In  isolating  the  third  division  at  the  foramen  ovale,  one  should  re- 
member that  a  few  millimeters  behind  it  the  middle  meningeal  artery, 
surrounded  by  the  two  portions  of  the  auriculo-temporal  nerve,  runs 
through  the  foramen  spinosum  into  the  cranial  cavity  (see  Fig.  256), 
Since  it  arises  from  the  internal  maxillary,  after  tying  this  otf  one  is 
rid  of  it,  and  for  this  reason  it  is  advisable,  even  in  resection  of  the  third 
division,  to  double  tie  and  divide  the  internal  maxillary  artery.  For  it- 
self this  ligature  is  not  necessary  in  order  to  reach  the  foramen  ovale; 
the  artery  may  be  pidled  to  one  side  readily  by  a  lilunt  retractor. 

One  must  further  give  attention  to  the  fact  that  just  medially  of 
the  foramen  ovale  lies  the  Eustachian  tube  which  if  opened  acciden- 
tally may  cause  not  only  damage  to  the  ear  but  also  trouble  with 
asepsis.  Accordingly  as  soon  as  one  has  exposed  the  third  division  so 
far  as  to  be  able  to  seize  it.  toward  the  middle  line,  one  should  not  con- 
tinue further  in  that  direction. 

The  foramen  ovale  may  be  divided  into  two  compartments  by  a 
bridge  of  bone. 

REMARKS  ON  THE  RESECTION  OF  THE  SECOND  AND  THIRD  DIVISIONS  AT 

THE  BASE  OF  THE  SKULL 

The  essential  principles  of  the  methods  described  go  back  to  Kron- 
lein;  but  the  incision  is  different.  Kronlein's  temporal  method  for 
the  simultaneous  exposure  of  the  second  and  third  divisions,  using  the 
Pancoast  method  of  resecting  the  coronoid  process,  represents  a  de- 
velopment of  the  operative  scheme  of  Liicke  (see  p.  225),  and 
to-day  stands  as  the  best  of  its  kind.  He  cuts  out  a  semicircular  skin 
tlap  in  the  region  of  the  temple  and  cheek,  the  base  corresponding 
to  the  upper  level  of  the  zygoma,  extending  forward  to  within  a 


RESECTION  AT  THE  BASE  OE  THE  SKULL  237 

finder's  breadth  of  the  outer  edoe  of  the  orbit  and  backward  close  in 
front  of  the  tragus:  its  vertex  hes  in  the  line  drawn  from  the  nasal 
orifice  to  the  lobule  of  the  ear.  The  flap  is  freed  up  from  the  parotido- 
masseteric  fascia,  the  zygoma,  and  the  lowermost  section  of  the  tem- 
])oral  fascia,  care  l)ein<>-  taken  to  avoid  the  branches  of  the  facial  nerve, 
the  duct  of  Steno  and  tlic  temporal  artery. 

Then  the  tcnij)()ral  fascia  is  freed  transversely  from  the  upper 
edge  of  the  zygoma,  the  periosteimi  is  divided  in  lines  corresponding 
with  the  two  oblitpie  incisions  in  front,  and  in  back  is  shoved  back- 
M-ards  sliglitly  with  the  elevator.  After  the  double  division  of  the 
/ygonia  Kronlein  pi'oceeds  as  previously  described.  Only  he  frees 
the  up])er  head  of  the  external  pterygoid  muscle  from  its  origin  on 
the  infratempoi'al  crest  and  the  lower  surface  of  the  greater  wing  of 
the  sphenoid  l)y  blunt  dissection  witli  an  elevator,  draws  it  downward, 
and  proceeds  at  once  from  the  upper  edge  of  the  muscle,  directly  in 
the  depths  toward  the  middle  line,  holding  close  to  the  base  of  the 
skull. 

By  the  method  of  Kronlein,  the  facial  branches  are  divided;  such 
lines  of  incision  should  be  avoided  so  far  as  possible.  For  it  is  not  a 
matter  of  little  moment  to  destroy  the  nerves  which  run  to  the  muscles 
which  shut  the  eye,  as  one  cannot  dejjend  upon  the  restoration  of  their 
function.  A  half-closed  eye  is  not  only  a  cosmetic  fault,  but  it  involves 
symj)toms  as  the  result  of  conjunctival  irritation  and  increased  se- 
cretion of  tears.  If  on  account  of  recurrence,  extirpation  of  the  Gas- 
serian  ganglion  is  to  be  considered,  an  existing  paresis  of  the  lower  lid 
is  a  source  of  danger  to  the  eye  (see  p.  243).  Kocher  upholds  the 
principle  that  one  should  avoid  the  facial  branches  as  far  as  possible 
and.  following  him,  M-e  employ  for  the  exposure  of  the  second  di- 
vision at  the  base  of  the  skull  the  incision  whicli  he  gives  for  the  third 
division  and  which  has  already  been  described. 

1  f  tlie  case  is  one  with  normal  tissues  and  if  there  are  no  operative 
scars  ])resent  in  the  region  of  the  temple,  this  incision,  according  to 
our  experience,  is  satisfactory;  it  has  the  advantage  that  only  tlie  facial 
fibres  which  go  to  the  frontalis  muscle  have  to  be  divided.  The  verti- 
cal incisions  of  Kronlein  in  such  a  case  are  unnecessary;  wlien  neces- 
sity requires  one  can  always  make  use  of  one  or  the  other  of  these  in- 
cisions, in  the  proper  length. 

Kocher  exposes  the  third  division  subperiosteally  just  at  the  fora- 
men ovale.  After  osteoplastic  resection  of  the  zygoma,  he  does  not 
divide  the  coronoid  process  of  the  lower  jaw .  but  pries  up  the  temjioral 


238  SURGERY  OF  THE  TRIFACIAL  NERVE 

muscle  along  its  posterior  edge  from  the  cranium  down,  allowing  it  to 
be  drawn  forward  considerably  with  a  blunt  retractor.  Only  in  case 
this  jjrocedure  does  not  give  enough  room,  does  he  divide  the  coronoid 
process  just  as  in  the  Kronlein  method.  Blunt  dissection,  according 
to  Kocher,  gives  a  clearer  operative  field  than  cutting  through  the 
coronoid. 

Hereupon  he  splits  the  periosteum  forward  from  the  anterior  root 
of  the  zygomatic  process  of  the  temporal  bone  along  the  infratemporal 
crest,  and  frees  it  medially  from  the  lower  sin-face  of  the  skull,  that 
is  to  say,  the  great  wing  of  the  sphenoid.  In  that  way  all  the  soft  parts 
are  removed  at  tlie  same  time  from  the  bony  base  of  the  skull  with- 
out the  least  injury.  Thus  lie  proceeds  to  the  origin  of  the  pterygoid 
process.  In  this  procedure  we  have  several  times  experienced  strong 
venous  hemorrhage  which  was  controlled  with  difficulty,  particularly 
on  account  of  the  limited  field  of  operation.  Now  proceeding  back- 
ward close  to  bone,  the  foramen  ovale  is  found  readily  palpable  just 
behind  and  a  bit  to  the  outside  of  the  sharp  corner  of  the  external  plate 
of  the  pterygoid,  on  an  average  3  cm.  deeper  than  the  anterior  root 
of  the  zygomatic  process  of  the  temporal  bone.  The  middle  menin- 
geal arterv  is  visible  behind  the  foramen  ovale,  and  the  internal  maxil- 
lary  and  its  other  branches  lie  in  the  soft  parts  which  have  been  pulled 
outwards,  protected  from  injury  by  the  covering  periosteum. 

In  many  cases  with  scar  contraction  there  develops  an  interference 
with  the  movability  of  the  jaw  which  may  reach  a  high  degree.  It 
demands  the  most  careful  treatment  with  the  Heister  mouth  gag. 
The  cause  is  clearly  injury  of  the  temporal  muscle  and  particularly  of 
the  insertion  of  its  powerful  tendon  into  the  coronoid  process.  This 
great  inconvenience  is  always  prevented  by  not  preserving  the  divided 
bony  process,  but  by  removing  it  Avith  the  tendon  of  the  temporal 
muscle,  the  method  originated  by  Pancoast.  By  this  procedure  the 
function  of  the  temporal  muscle  affected  is  permanently  destroyed, 
but  on  the  other  hand  there  are  no  later  disturbances.  The  removal 
of  the  third  division  at  the  foramen  ovale  leads  to  incurable  paralysis 
of  the  muscles  of  mastication  on  the  affected  side,  including  the  tem- 
poral muscle. 

THE  SIMULTANEOUS  RESECTION  OF  THE  THREE  DIVISIONS 

If  all  three  divisions  are  affected,  one  may  remo\e  tliem  at  one  sit- 
ting. We  have  found  the  following  succession  practical.  ^Vfter  the 
supratrochlear  nerve  is  resected    (see  p.  213),  the  supraorbital  in- 


Krause-Heyniann-Ehrenfried. 


Tab.  52. 


Extirpation   of  tlic  Gasscrian   L;ani::,"lion. 
\ 


Fig.  273.  Exposure  of  the  Sr^i  and  2nd  divisions,  after 
ligature  of  the  middle   meningeal  artery. 


Fig.  275.  Extirpated  Oasserian 

ganglion  together  with  the  trifacial  root 

(natural  size). 


Fig.  274.  Previous  exposure  of  the 
middle  meningeal  artery. 


Rebniaii  (-oinpany,  New  V'ork. 


EXTIRPATION  OF  THE  GASSERIAX  GANGLION  239 

cision  is  made  continuiiinr  the  zygomatic  incision  described  on  page  222, 
and  the  entire  second  division  is  removed  in  the  described  manner. 
For  the  exposure  of  the  tliird  division  at  the  foramen  ovale  it  is  ad- 
visable first  to  divide  the  internal  maxillary  artery  between  two  liga- 
tures and  to  extirpate  it  as  far  as  possible  in  front  and  behind,  tying 
off  each  separate  branch.  In  that  way  one  avoids  all  arterial  hemor- 
rhage. 


EXTIRPATION  OF  THE  GASSERIAX  GANGLIOX 

For  anatomical  relations  see  Fig.  24'I,  jjage  214,  and  Fig.  242, 
page  21G. 

A  fifty-one-year-old  man  had  suffered  for  eight  years  with  severe 
right  trifacial  neuralgia  in  the  region  of  the  second  and  third  divisions; 
four  pcrij)heral  resections  had  been  undertaken  with  temporary  re- 
sults. Tlie  last  operation,  December,  1908,  was  for  the  removal  of  the 
second  and  the  third  divisions  at  the  base  of  the  skull  after  the  method 
of  Kronlein.  The  scar  over  the  zygoma  was  depressed  a  finger's 
breadth,  as  the  zygoma  had  not  healed  in  position,  but  had  been  dis- 
placed markedly  downward.  The  mouth  could  only  be  opened  so  far 
as  to  make  a  narrow  chink  between  the  front  teeth;  the  right  eyelid 
could  oidy  l)e  incompletely  closed.  The  neuralgic  attacks  were  un- 
commonly severe  and  occiuTed  most  frequently  at  night,  so  that  the 
patient  for  months  could  not  eat  or  sleep  normally  and  had  suffered 
greatly  in  nutrition.  We  decided  to  extirpate  the  Gasserian  ganglion 
and  the  trifacial  root,  which  was  done  on  October  25,  1909. 

The  patient  was  placed  on  the  operating  table  in  the  half  sitting 
posture,  the  head  lying  backwards,  an  assistant  holding  it  directed  ex- 
actly forward,  but  tunu'ng  it  a  bit  as  occasion  required  to  the  affected 
side  in  order  that  blood  which  collected  in  the  depths  of  the  wound, 
as  well  as  the  sniall  aniount  of  cerebro-spinal  fluid  which  came  away, 
could  run  out  and  not  disturb  the  view.  After  a  preliminary  dose  of 
scopolominc-morphiiu'.  under  chloroform  anesthesia,  an  acupressure 
needle  was  inserted  above  the  zygoma  through  the  entire  thickness  of 
the  soft  parts  so  as  to  surround  and  exclude  the  temporal  artery,  after 
the  method  of  Heidenhain. 

In  the  region  of  the  ten)poral  muscle  a  flap  was  formed  after  the 
method  of  ^Vaguer,  with  a  base  l)elow,  which  was  composed  of  skin, 
fascia,  muscle  and  bone  (Figs.  273,  274,  275,  Plate  52).    The  incision 


240  SURGERY  OF  THE  TRIFACIAL  NERVE 

began  above  the  zygoma,  which  did  not  have  to  be  injured  in  the  least, 
close  in  front  of  the  tragus;  it  ran  convexly  backward  and  upward 
describing  a  half  circle,  and  came  forward  and  downward  in  a  convex 
fashion  back  to  the  zygoma,  so  that  the  base  of  the  flap  was  4  cm.,  its 
height  6  cm.,  and  its  widest  point  above  5l/o  cm.  The  incision  pene- 
trated all  the  layers  down  to  bone  practically  without  bleeding.  The 
periosteum  was  stripped  somewhat  to  each  side  and  the  skull  was 
divided  along  the  entire  line.  At  the  upper  margin  of  tlie  bony  flap  a 
hole  was  made  in  front  and  in  back  witli  a  bm-r  drill  and  starting  from 
these  the  bone  was  cut  with  Dahlgren  forceps,  after  having  loosened 
the  dura  from  the  inner  surface  of  the  bone  by  means  of  a  Braatz 
guide. 

The  flap  of  bone  and  soft  parts  was  broken  downwards  with  an 
elevator  so  that  the  dura  mater  was  exposed  (Fig.  273,  Plate  52). 
This  was  very  thin  and  had  grown  fast  to  the  lamina  vitrea  so  that 
great  care  had  to  be  exercised  in  order  not  to  tear  the  entire  din-a  away 
from  the  bony  opening;  this  Avould  have  greatly  increased  the  diffi- 
culty of  the  operation.  The  line  of  fracture  in  the  skull  ran  trans- 
versely in  a  zigzag  line  just  above  the  zygoma;  as  is  always  the  case,  a 
strip  of  bone  about  1  cm.  wide  had  to  be  removed  with  rongeurs,  to  get 
rid  of  the  margin  of  bone  below,  which  obstructed  the  view,  down  to 
the  base  of  the  skull,  that  is  to  say,  to  the  infratemporal  crest.  This 
rule  should  never  be  forgotten,  the  base  of  the  skull  must  be  freely 
exposed,  or  the  procedure  is  rendered  very  difficult.  The  bony  plate 
was  made  fast  with  two-toothed  forceps,  in  order  that  it  should  not  be 
loosened  from  the  periosteum.  Only  a  few  vessels  had  to  be  tied. 
From  the  posterior  edge  of  the  bony  opening  another  small  strip  of 
bone  had  to  be  removed. 

The  flap  hvmg  practically  by  skin  and  temporal  muscle,  and  by 
freeing  the  latter  together  with  periosteum  from  tlie  greater  wing  of 
the  sphenoid  and  from  the  temporal  fossa  somewhat  further  down- 
wards with  the  raspatory,  the  flap  could  be  laid  do^vn  completely  so 
that  its  skin  surface  lay  upon  the  skin  of  the  cheek.  It  was  wrapped 
in  gauze  and,  with  the  clamps  which  were  attached,  in  the  half-sitting 
position  of  the  patient,  it  hung  down  low  enough  so  that  no  pull  had 
to  be  exerted  on  the  sharp  retractors  which  were  placed  in  the  tem- 
poral muscle.  The  dura  mater  was  exposed  to  the  point  where  it 
turned  onto  the  base  of  the  skull.  The  cerebral  tension  in  this  ease 
was  extraordinarily  great,  rendering  the  operation,  which  naturally 
proceeded  extradurally,  considerably  more  difficult. 


Krause-Heymann-Elirenfried 


Tab.  53. 


Extirpation   of  the  Gasserian  ganglion. 


Eminentia  capitnta 

Fig.  276.  Chiseling  away  the  projecting  eminence. 

//  division 


III  division 


Fig.  278.  Exposure  of  2n'i  and  S^d  divisions. 

Trifacial  root 


Fig.  280.  Twisting  out  the  trifacial  root. 
Rebman  Company,  New  York. 


Small  sponge 

Fig.  277.  Lifting  away  the  dura  in  the 
middle  fossa. 


///  division 


Tenotome 


Fig.  279.  The  ganglion  is  seized  transversely,  and  the 
2"d  and  3rd  divisions  are  cut  across. 


Trifacial  root 


Motor  root 


Season'  root 


Gasserian  ganglion 


J  2""' division 

3'''' division 

Fig.  281.  The  specimen  removed  (natural  size). 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION  2^1 

The  dura  was  now  freed  up  from  the  base  of  the  skull  in  the  middle 
fossa  by  blunt  dissection.  Difficulty  developed  first  on  account  of  the 
unusual  tension,  and  second  because  the  dura  was  remarkably  tliin 
and  had  grown  fast  to  the  bone  and  accordingly  in  loosening  up  tore  in 
several  places.  Xe^"ertheless  it  was  successfully  loosened  in  the  typical 
manner  by  using  in  turn  the  fingers,  small  sponges  held  in  forceps,  and 
the  elevator. 

One  of  the  eminentia  capitata  projected  so  far  into  the  middle  fossa 
that  it  had  to  be  leveled  off  with  the  chisel  in  order  not  to  interfere  with 
the  view  in  the  depths  (Fig.  276,  Plate  53).  Likewise  in  front  the 
second  eminentia  capitata  had  to  be  chiseled  off.  This  allowed  us  to 
proceed  in  the  customary  manner  as  far  as  the  foramen  spinosuni. 
As  the  dura  under  strong  tension  was  carefully  lifted  with  a  brain 
retractor,  the  n)iddle  meningeal  artery  was  seen  to  be  very  small  and 
showed  no  pulsation.  It  was  torn  through  with  the  elevator  without 
hemorrhage  residting.  Clearly  the  earlier  operator  had  ligated  the 
internal  maxillary  artery  according  to  the  method  of  Kronlein  and  in 
that  way  had  excluded  the  middle  meningeal  artery.  The  typical 
method  of  ligating  and  dividing  this  artery  is  shown  in  Plates  52,  54 
and  ~)o. 

iVfter  disposing  of  the  middle  meningeal  artery  the  retractor  was 
allowed  to  remain  and  Ave  proceeded  gradually  towaid  the  middle 
line,  lifting  up  the  dura  with  an  elevator  or  small  sponge,  always 
avoiding  with  the  utmost  care  any  pressure  upon  the  brain.  From 
time  to  time  this  procedure  had  to  be  interrupted  to  control  bleeding. 
We  then  packed  the  wound  below  the  retractor  to  its  deepest  point 
with  sterile  gauze,  which  we  pressed  firndy  against  the  base  of  the 
skull.  This  controlled  the  oozing  from  the  bone,  and  if  the  brain 
within  the  dura  was  allowed  to  sink  back  into  its  natural  position 
bleeding  from  the  dural  veins  ceased  at  once. 

Soon  the  third  division  came  into  view  and,  a  little  further  to  the 
middle  line  and  in  front,  the  second  division  (Fig.  278,  Plate  5.'}). 
In  order  to  free  up  both  in  their  entire  extent  from  the  ganglion  to 
their  foramina  of  exit,  we  stripped  the  dura  back  from  the  nerves  and 
lifted  them  from  the  underlying  bone  on  a  blunt-pointed  bent  elevator. 
Tiiis  same  procedure  was  also  performed  upon  the  ganglion  itself, 
with  complete  success,  after  a  few  thin  but  particularly  firm  strands 
of  connective  tissue  here  and  there  were  divided  with  the  points  of  the 
scissors.  Ordinarily,  however,  blunt  dissection  with  a  s])onge  sufTieed. 
The  dura  was  lorn  again  in  one  small  place  and  some  cercbro-spiual 


242  SURGERY  OF  THE  TRIFACIAL  NERVE 

fluid  came  out.  Finally  the  ganglion  was  loosened  up  below  from  the 
bone  on  a  bent  elevator  and  in  this  way  was  completely  freed. 

While  the  elevator  was  allowed  to  remain  in  place,  the  nerve  clamp 
with  longitudinal  ridges  was  shoved  all  the  way  under  the  ganglion 
near  its  junction  with  the  trifacial  root,  and  seized  it  firmly  (Fig.  279, 
Plate  53).  We  took  particular  care  that  neither  a  fold  of  dura  nor 
the  wall  of  the  sinus  cavernosus,  nor  one  of  the  motor  nerves  of  the 
eye  were  seized  at  the  same  time  in  the  point  of  the  forceps  medially. 
Then  the  second  division  was  divided  at  the  foramen  ovale  with  a 
curved  tenotome  (Fig.  279,  Plate  53) .  The  elevator  under  the  gang- 
lion was  removed  and  the  nerve  clamp  slowly  twisted  on  its  axis  so 
that  the  trifacial  roots,  motor  and  sensory,  were  twisted  out  (Figs. 
280  and  281,  Plate  53).  Finally  with  the  elevator  the  peripheral 
stumps  of  the  second  and  thiid  divisions  were  pushed  as  far  as  ^jossible 
into  their  foramina,  and  once  more  we  examined  the  surface  of  the 
cavum  INIecklii.  which  was  now  completely  emptied  of  its  contents,  and 
lay  freely  exposed  in  its  entii-e  extent  as  far  as  the  upper  margin  of 
the  petrous  portion.  We  saw  further,  that  the  foramina  ovale  and 
rotundum  were  completely  empty. 

A  strip  of  vioform  gauze  was  laid  in  the  depths  of  the  wound  down 
to  the  foramen  rotundum,  since  there  was  still  some  venous  bleeding 
from  this  point,  and  a  gauze  drain  in  the  posterior  lower  corner  of  the 
wound  to  prevent  the  collection  of  blood.  Then  the  periosteum  and 
muscle  of  the  flap  were  sewed  up  with  five  interrupted  catgut  sutures 
and  the  skin  was  sewed  with  silk.  The  wound  healed  without  inci- 
dent. On  the  foin-th  day  the  packing,  and  on  the  sixth  day  the  drain 
was  removed;  on  the  twelfth  day  the  patient  was  allowed  to  get  up. 
Four  months  later  the  patient,  who  had  been  pensioned  on  account 
of  his  sufferings,  gave  up  his  pension  and  has  remained  ever  since  with- 
out pain. 

PREPARATION 

This  operation,  which  at  times  is  quite  severe,  req>]ires  certain  fur- 
ther consideration.  As  regards  preparation,  it  is  important  to  empty 
the  bowels  before  operation,  in  order  that  the  patient,  who  is  apt  to 
suffer  from  constipation  as  a  result  of  the  use  of  morphine,  will  have 
no  distress  during  the  first  few  days.  The  head  need  be  shaved  only 
over  a  considerable  extent  on  the  temporal  region  of  the  affected  side; 
in  Avomen  it  seems  inconsiderate  to  remove  all  the  hair.  Tn  such  a 
case  psychoses  may  follow,  which  will  disappear  only  after  the  hair  has 


EXTIRPATION  OF  THE  GASSERIAX  GANGLION  243 

regrown.    The  external  ear  is  cleansed  mechanically,  washed  out  with 
3  per  cent,  horic  acid  solution  and  plugged  with  sterile  gauze. 

KERATITIS  NEUROPARALYTICA 

As  regards  preparation  of  the  eye,  we  formerly  considered  it  neces- 
sary for  the  j)revention  of  neuroparalytic  keratitis  to  give  atropine; 
we  no  longer  hold  this  view.  In  order  that  the  eye  shall  not  be  irri- 
tated, it  is  irrigated  before  operation  with  boric  acid  solution.  The 
practice  of  sewing  up  the  eyelids  is  not  to  l)e  reconmiended,  because  it 
interferes  with  the  view  of  the  conjunctiva.  If  suppuration  of  the 
lachrimal  sack  occurs,  considerable  danger  arises.  We  have  twice  seen 
hypopyon-kei-atitis  occur.  Once  it  healed  inider  applications  of  atro- 
pine and  chlorine  water  with  a  hardly  visible  corneal  opacity;  In  the 
second  case,  however,  where  lagophthalmos  paralytica  was  present  as 
the  resvdt  of  a  I^iicke  operation  carried  out  on  the  other  side,  the  sup- 
puration partly  on  account  of  the  poor  closin-e  of  the  lid  and  the  dry- 
ing which  resulted,  progressed  over  the  conjunctiva  and  resulted  in 
the  loss  of  the  eye.  Particular  attention  is  required  by  patients  in 
whom,  as  the  result  of  an  earlier  peripheral  operation,  closin-e  of  the 
lids  is  hindered  by  paralysis  of  the  trifacial  (see  p.  237)  ;  in  two 
cases  of  this  sort  under  the  moist  eye  dressing  wliich  was  still  used 
at  that  time,  although  it  was  changed  morning  and  evening,  we  have 
seen  a  defect  develop  in  the  epithelium  of  the  conjunctiva  across  the 
eye  in  a  transverse  strip  which  exactly  corresponded  to  the  edge  of  the 
up])er  lid  when  it  was  closed.  The  weight  of  the  bandage  sufficed 
to  determine  a  slough  in  the  conjunctiva,  which  had  been  robbed  of 
its  innervation,  at  a  place  corresponding  to  the  sharp  inner  edge  of  the 
hd. 

Since  that  observation  we  have  dispensed  with  dressings  for  the 
protection  of  the  cornea  and  have  employed  a  large  watch  glass  such  as 
is  used  to  protect  the  well  eye  in  cases  of  piundent  inflammation.  A 
round  hole  half  the  size  of  the  glass  is  cut  in  a  square  piece  of  zinc 
oxide  adliesive,  which  is  then  used  to  stick  it  down  about  the  edge  of 
the  orbit.  The  moist  chamber  forms  the  best  ])rotcction  for  the  con- 
junctiva; also  small  pressure  sores  of  the  epithelium,  using  atropine 
if  necessary,  heal  in  imder  the  watch  glass  witliout  disturbance.  We 
change  the  adhesive  every  twenty-four  hours  and  delicately  irrigate 
the  eye,  but  never  douche  it.  The  protective  glass  is  employed  as 
long  as  any  disposition  to  inflammation  or  irritation  is  seen. 

It  has  been  said  that  trifacial  keratitis  may  be  avoided  if  the  gan- 


244  SURGERY  OF  THE  TRIFACIAL  NERVE 

glion  itself  is  not  removed  and  the  roots  alone  are  divided,  as  done  by 
Victor  Horsley  as  far  back  as  1891,  but  with  unhappy  result.  With- 
out iloubt  this  exi^edient  produces  a  lasting  break  in  the  nerve  con- 
ductivity and  guarantees  cure  of  the  typical  trifacial  neuraligia  in  so 
far  as  it  has  its  cause  in  the  Gasserian  ganglion  or  in  the  periphery,  but 
physiology  teaches  us  that  the  destruction  of  a  sensory  root  is  never  re- 
paired. This  can  no  more  happen  after  division  of  the  root  of  the 
trifacial  or  complete  extirpation  of  the  Gasserian  ganglion  than  after 
dividing  a  posterior  spinal  root  between  cord  and  spinal  ganglion  or 
after  removal  of  the  spinal  ganglion.  But  the  ganglion  operation  is 
less  dangerous,  and  for  that  reason  is  entitled  to  the  preference;  never- 
theless indications  for  division  of  the  trifacial  root  may  arise,  and  we 
will  say  something  more  about  this  later. 

We  have  in  several  cases  after  extirpation  of  tumors  at  the  cerebello- 
pontine angle  observed  neuroparalytic  keratitis,  and  in  tAvo  patients 
as  early  as  twenty-four  hours  after  operation.  In  all  these  cases  the 
cerebellum  was  meclianically  injured  and  shoved  to  one  side,  and  in 
that  way  the  trifacial  root  was  torn.  But  we  have  proceeded  over  tlie 
upper  edge  of  the  petrous  portion  of  the  temporal  bone  forward  to 
the  middle  fossa,  that  is  to  say  to  the  neigh])orhood  of  the  Gasserian 
ganglion,  onl}'  a  few  times.  These  cases  we  will  leave  out  of  consid- 
eration here;  for  in  them  the  trifacial  root  as  well  as  the  Gasserian 
ganglion  may  be  injured.  We  have  repeatedly  observed  neuroparaly- 
tic keratitis  after  injury  or  tear  of  the  trifacial  root  limited  to  the 
posterior  fossa.  This  happened,  for  example,  in  a  patient  thirty  years 
old  in  whom  a  tumor  of  the  cerebello-pontine  angle  was  readily  re- 
moved. She  showed  an  important  diagnostic  sign,  areflexia  of  the 
affected  conjunctiva.  Five  daj'^s  after  operation  a  definite  keratitis 
developed,  which  healed  slowly  under  a  watch  glass  and  the  use  of 
atropine  and  boric  acid  drops.  But  as  soon  as  the  watch  glass  w^as 
left  off  for  twelve  hours  the  conjunctiva  became  inflamed  again  and  a 
year  later  the  inflammation  Avas  still  present. 

Our  observations  show"  the  mistake  of  the  assuming  that  only  injmy 
of  the  Gasserian  ganglion  causes  danger  to  the  eye,  and  that  injury  or 
resection  of  the  trifacial  root  does  not  lead  to  neuroparalytic  keratitis. 
Our  observations  have  been  entirely  clinical,  but  on  the  other  hand, 
Sultan  has  shown  by  experiments  on  dogs  that  cutting  the  root 
likewise  causes  keratitis,  for  of  five  dogs  operated  only  one  escaped 
inflammation. 

The  danger  to  the  eyes  in  men  is  not  nearly  so  great  as  in  animals; 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION  245 

at  least  we  have  seen  many  cases  of  keratitis  after  extirpation  of  the 
Gasserian  <»'an<>lion,  often  in  the  most  severe  form,  clear  up  under  suit- 
able treatment  (rest  in  bed,  atropine,  boric  acid  solution,  watch  glass). 
After  extirpation  of  the  ganglion  the  danger  of  keratitis  is  greater 
just  after  operation  than  later,  although  the  anesthesia  of  the  eye  is 
lasting.  For  instance,  one  case  operated  January  31,  1893,  at  that 
time  sixty-eight  years  old.  is  still  living  in  good  health.  .Soon  after 
the  extirpation  she  developed  nein-oparalytic  keratitis,  and  since  that 
time,  although  she  has  taken  no  precautions,  has  been  free  of  any  fur- 
ther inflammation;  and  we  might  cite  many  other  similar  cases. 

REMARKS  ON  TECHNIQUE 

If  scar  depression  at  the  zygoma  as  the  result  of  earlier  operations 
endanger  the  nourishment  of  the  skin  and  bone  flap,  the  base  of  the 
flap  may  be  laid  jjosteriorly.  The  transverse  division  of  the  temporal 
muscle  at  its  lower  edge  is  immaterial,  as  resection  of  the  third  di- 
vision at  the  base  of  the  skull  causes  permanent  parah'sis  of  the 
muscles  of  mastication.  However,  the  base  of  the  flap  should  ordi- 
narily come  below,  as  in  this  way  the  bony  plate  is  best  nourished. 

The  hemostatic  suture  of  Ileidenhain  prevents  loss  of  blood;  accord- 
ingly with  this  technique  one  can  best  preserve  the  bone.  ^Nlore- 
over,  if  the  bone  is  removed,  in  the  course  of  time  the  entire  temporal 
region  becomes  depressed.  In  operating  under  adrenalin-novocain, 
the  Heidenhain  acupressure  method  is  not  necessary. 

In  certain  cases  we  find  the  dura  grown  so  fast  to  the  lamina  vitrea 
that  it  is  torn  in  freeing  it  with  the  Eraatz  guide,  or  it  is  cut  with  the 
Dahlgren  bone  forceps.  In  such  case  one  must  be  very  careful  in 
turning  down  the  bony  plate  not  to  tear  the  dura  off  over  the  entire 
opening.  With  a  thin  and  friable  dura  one  should  proceed  very  care- 
fully along  the  base  of  the  skull. 

The  length  of  the  brain  retractor  (see  Plates  ;)2  and  o3)  is  about 
8  cm.;  the  distal  5  cm.  is  ribbed.  In  ordinary  skulls  the  end  of  the 
handle,  if  it  is  held  oblifpiely,  lies  against  the  skull,  giving  the  assistant 
a  ])oiiit  of  support.  In  very  wide  skulls  it  would  be  of  advantage  to 
have  the  retractor  I  or  2  cm.  longer.  It  should  lift  the  brain  in  its 
dural  envelope  upwards  very  slightly,  but  should  not  force  it  toward 
the  middle  line.  In  certain  cases  the  sui'geon  may  hold  the  I'etractor 
with  the  left  hand,  while  operating  with  the  right.  The  handle  of  a 
bent  silver  spoon  can  be  readily  adapted  for  the  purpose. 


246  SURGERY  OF  THE  TRIFACIAL  NERVE 

LIGATION  OF  THE  MIDDLE  MENINGEAL  ARTERY 

In  freeing  up  the  dura  from  the  floor  of  the  middle  fossa,  one  comes 
first  to  the  foramen  spinosiim  and  the  middle  meningeal  artery,  which 
enters  the  cranial  cavity  at  this  point.  As  a  rule  this  should  be  tied 
off  and  diA'ided.  For  this  purpose  the  brain  in  its  intact  dura  should 
be  lifted  carefully  by  the  operator  or  assistant  with  a  right  angle 
retractor  about  3  cm.  wide,  but  only  so  far  as  is  absolutely  necessary 
for  -vision. 

A^'hile  the  dura,  just  after  opening  the  cranial  cavity,  is  ordinarily 
under  considerable  tension,  it  now  becomes  more  lax  and  gives  plenty 
of  room  for  vision  and  for  operating.  In  lifting  up  the  dura  the  mid- 
dle meningeal  with  its  accompanying  veins  appears  as  a  distinct  cord, 
running  up  to  it  from  the  foramen  spinosimi.  If  one  loosens  the  dura 
from  the  base  of  the  skull  somewhat  to  the  middle  side  of  the  artery 
with  an  elevator  so  that  the  second  and  third  divisions  are  visible,  the 
vascular  cord  becomes  isolated  on  all  sides  (see  Plates  52,  54  and  55), 
and  one  can  then  expose  it  to  the  extent  of  about  Y^  cm.  and  without 
difficulty  carry  a  strand  of  small  catgut  around  it  with  a  flexible  probe 
or  fine  ligature  carrier.  One  now  applies  a  fine  hemostat  between 
dura  and  foramen,  ties  off  below  it,  removes  the  hemostat,  and  cuts 
the  artery  just  at  the  dura.  The  vessel  is  now  so  well  freed  up  that 
even  if  the  ligature  slips  off,  the  vessel  can  be  seized  again.  The  cat- 
gut, on  account  of  the  depth  of  the  wound,  may  best  be  tied  between 
forceps.  The  technique  described  is  so  simple  that  it  may  be  used  for 
typical  hgation  of  the  trunk  of  the  middle  meningeal  in  other  cases 
also. 

In  a  certain  few  cases  the  ligature  has  slipped  off  because  the  artery 
was  cut  too  close.  If  the  stump  cannot  be  seized  again,  the  bleeding 
is  immediately  controlled  by  finger  pressure,  while  a  fine  end  of  gauze 
is  packed  tightly  into  the  foramen  spinosum  with  a  blunt-pointed  in- 
strument and  allowed  to  remain  for  five  days.  The  operation  does  not 
have  to  be  interrupted.  In  many  cases  in  which  on  accoimt  of  arterio- 
sclerosis, the  ligature  has  cut  through,  a  blimt  right  angle  wedge- 
shaped  hook  is  introduced  into  the  orifice,  is  packed  in  tightly  with 
a  raspatory,  and  is  twisted  back  and  forth  until  the  bleeding  has  en- 
tirely ceased ;  or  it  may  be  allowed  to  remain  during  the  entire  opera- 
tion. If  bleeding  is  re-established  on  ])ulling  out  the  hook,  it  stops 
if  the  foramen  is  packed  tightly  with  gauze  or  if  the  hole  is  plugged 
with  dental  cement. 

Some  operators  do  not  tie  the  artery.     It  is  possible  to  extirpate 


EXTIUrATIOX  OF  Tin:  r.ASSF.RIAX  GAXGT.IOX  2^7 

the  ganglion  witliout  tying  in  case  the  foramen  spinosum  is  unusually 
far  hack  of  the  foramen  ovale.  IJnt  nevfrtheless  it  is  safer  to  ligate 
and  divide,  and  this  must  he  held  as  a  principle. 

\'ENOUS  HEMOKRHAGE 

Hemorrhage  arises  from  another  source  as  soon  as  one  begins  to  free 
up  the  dura  from  the  ])ase  of  the  skull.  This  bleeding  is  diffuse  and 
generally  of  considerable  quantity,  hut  it  is  practically  always  venous. 
Its  predominating  source  is  the  veins  of  the  dura;  secondarily  the 
small  emissary  veins  of  Santorini.  These  are  torn  in  separating  dura 
from  the  inner  surface  of  tlie  skull,  and  they  are  much  more  numerous 
than  the  anatomical  text  hooks  would  give  one  to  believe.  This  dis- 
turbing hemorrhage  is  diminished  if  one  makes  the  separation  be- 
tween dura  and  the  base  of  the  skidl  rapidly,  using  at  first  the  fore- 
finger, and  it  is  greater  if  one  dissects  slowly  with  a  blunt  dissector. 
This  rapid  technique  can  be  used  at  first  without  worry,  because  no 
dangerous  increase  in  brain  pressure  can  result;  the  finger  can  be 
used  until  one  reaches  the  foramen  spinosum.  Then  the  brain  ele- 
vator is  inserted  for  the  first  time.  Often  a  slight  alteration  in  the 
angle  of  the  elevator  or  an  insignificant  change  in  its  position  back- 
wards or  forwards  sufHces  to  control  this  bleeding  during  the  further 
course  of  the  operation. 

If  local  anesthesia  is  employed  venous  bleeding,  from  the  effect 
of  the  adrenalin,  becomes  slight  or  is  entirely  absent.  In  general 
anesthesia  s2)onges  soaked  in  adrenalin  may  be  used  with  advantage. 

MANIPULATION  OF  THE  GASSERIAN  GANGLION 

If  one  seizes  the  third  division  with  a  small  hemostat  and  puts  it  on 
the  stretch,  the  ganglion  is  pulled  out  somewhat,  which  makes  the 
exj)osure  more  easy;  for  this  reason  the  three  trunks  should  be  cut 
through  first,  as  they  hold  the  ganglion  fast  in  its  position.  In  every 
case  expose  the  ganglion  as  far  as  its  inner  edge,  and  as  far  back- 
wards as  the  up])er  margin  of  the  ])ctrous  portion,  so  that  the  trifacial 
root  is  visible.  The  ganglion  looks  like  a  network  of  fibres,  and  is 
grayish-red  in  coloi-.  The  trifacial  root  is  practically  always  white 
and  striped  (Fig.  275,  Plate  .52). 

The  first  division  is  intentionally  exposed  only  at  its  point  of  junc- 
tion with  the  ganglion  and  not  in  its  fin-ther  course,  as  is  always  neces- 
sary for  the  second  and  third  divisions.  For  it  runs  forward  in  the 
wall  of  the  sinus  cavernosus,  and  although,  as  we  have  shown,  it  may 


948  SURGERY  OF  THE  TRIFACIAL  NERVE 

be  dissected  free  of  tliis  on  tlie  cadaver,  conditions  in  the  living  are 
less  favorable.  Moreover,  in  its  immediate  neighborhood  lie  the  ab- 
ducens  an.d  the  trochlear  nerves  and  further  to  the  middle  line  the 
oculo-motor;  all  injury,  tearing  or  crushing  of  these  nerves  must  be 
avoided. 

Twice  we  have  injured  the  sinus  cavernosus;  in  a  moment  alarming 
hemorrhage  ensues,  but  if  one  packs  in  a  small  sponge,  the  bleeding 
is  controlled,  and  the  operation  may  be  completed  without  difficulty. 
As  the  brain  is  allowed  to  sink  back  in  its  normal  position,  after  the 
operation  is  over,  the  bleeding  ceases  usually  without  further  atten- 
tion: the  jjressure  in  the  sinus  is  very  low.  If  not,  one  must  leave  a 
small  strip  of  gauze  packed  against  the  bleeding  point,  with  the  end 
coming  out  through  the  wound. 

After  the  ganglion  together  with  the  second  and  third  divisions  are 
completely  freed,  in  order  to  be  assured  against  all  eventualities,  it  is 
seized  behind  obliquely  by  the  nerve  clamp  at  the  point  where  it  goes 
over  into  the  trifacial  root,  that  is  to  say,  just  in  front  of  the  upper 
edge  of  the  jjetrous  portion  and  close  below  the  superior  petrosal  sinus, 
before  one  undertakes  anything  further.  This  jioint  is  marked  in 
the  Figin'e  282  by  the  black  wire  which  is  passed  through  it. 

In  dividing  the  second  and  third  divisions  at  the  foramina  rotundimi 
and  ovale  bleeding  occurs;  for  certain  small  arteries  and  veins  go 
through  the  foramina  and  in  addition  emissary  veins  of  a  certain  con- 
siderable size  which  connect  the  sinus  cavernosus  and  the  pharyngeal 
and  pterygoid  venus  plexuses.  This  hemorrhage  usually  stops  of 
itself,  l)ut  in  any  case,  since  it  has  its  origin  in  the  neighborhood  of  the 
bony  canals,  it  is  easily  controlled.  One  simply  bores  with  a  dull 
instrument  into  the  canal  or  stuffs  gauze  into  it  for  a  time  imder 
moderate  pressure. 

On  twisting  the  clamp  the  entire  ganglion  follows,  and  in  addition 
a  greater  or  less  extent  of  the  centrally  situated  trifacial  root.  The 
first  division  usually  tears  off  close  to  the  ganglion.  Since  only  the 
peripheral  portion  of  it  remains  behind,  from  the  point  of  view  of  the 
organism  it  is  completely  removed,  as  is  demonstrated  by  the  com- 
plete and  permanent  anesthesia  of  cornea  and  conjunctiva  that  results. 

If  one  examines  the  cavum  Meckelii,  the  depression  will  be  seen  to 
be  empty.  Close  behind  the  foramen  ovale  in  many  cases  will  be  seen 
not  bone,  but  a  gray-reddish  mass  which  clearly  has  been  torn  up  from 
bone,  consisting  of  the  stiff  fibrous  or  fibro-cartilaginous  tissue  which 
at  times  occurs  just  in  front  of  the  entrance  of  the  internal  carotid  into 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION 


249 


the  cranial  cavity,  and  forms  the  upper  lateral  wall  of  the  carotid  canal, 
and  in  conjiiiiction  with  a  thin  periosteal  layer  alone  separates  the 
lower  surface  of  the  Gasserian  <)an<>lion  from  tiie  large  artery.  This 
relation  we  have  heen  able  to  establish  definitely  in  three  operations. 
For  that  reason  one  should  use  no  sharp  instrument  in  loosening  up 
the  Gasserian  ganglion  from  the  bone,  and  even  the  elevator  should  not 
l)e  sliarp. 


Internal  carotid  artery   , 
Dura  mater 


I,  division 


II.  division 


HL  division 


Skin,  muscle,  periosteum, 
bone  flap 


Trifacial  root 


Oasserian  gang'.lcn 


Middle  meningeal 
artery,  tied 


Fig.  282 

Operative  FieIjD  for  Removal  of  tiik  Gasserian  Ganglion  After  V.  Krause 
Photofraph  about  one-half  natural  .size.     On  the  cadaver  the  brain   had  to  be  lifted  up, 
to  get  light  into  the  deptlis  of  the  wound,  much  mor.e  than  is  ever  necessary  on  the  living 
subject. 

Moreover  the  carotid  in  its  exit  from  its  canal  lies  very  close  to  the 
inner  edge  of  the  ganglion  and  of  the  trifacial  I'oot,  but  always  far 
enough  in  order  to  be  ])rotected  from  injury  if  necessary  care  is  used. 
At  times  it  is  suri-ounded  by  the  sinus  cavernosus.     If  one  injudi- 


'250  SURGERY  OF  THE  TRIFACIAL  NERVE 

ciously  advances  too  far  over  the  medial  boundary  of  the  root  and  of 
the  ganglion  the  sinus  will  be  torn  and  very  disturbing  bleeding  will 
result.  In  none  of  om*  operations  has  the  internal  carotid  been  in- 
jured. If  this  mischance  actually  happened,  packing  the  canal  with 
gauze  would  have  controlled  the  bleeding.  This  packing,  on  account 
of  the  size  of  the  vessel  and  the  intravascular  blood  pressui'e,  should 
be  allowed  to  remain  at  least  eight  or  ten  days.  Filling  the  canal  with 
cement  is  a  safer  method. 

The  length  of  time  consumed  by  the  operation  depends  largely  on 
the  amount  of  hemorrhage  and  the  time  which  is  required  for  its  con- 
trol. With  considerable  bleeding  one  must  work  slowly,  and  inter- 
rupt the  jjrocedure  with  careful  sponging  in  order  that  all  the  neces- 
sary procedures  can  be  carried  on  in  the  depths  of  the  wound  imder 
direct  guidance  of  the  eye.  But  even  if  the  operation  takes  a  long 
while,  it  should  be  finished  at  one  sitting,  except  under  the  utmost 
necessity.  It  is  hardly  reasonable  to  submit  a  person  who  has  been 
rendered  weak  through  long  and  severe  pain  to  the  danger  of  opera- 
tive procedures  twice  within  a  short  sjiace  of  time. 

Ordinarily  the  one  stage  operation  with  preservation  of  the  bone 
takes  an  hour  to  an  hour  and  a  half.  "With  slight  bleeding  it  may  be 
done  in  twenty  to  twenty-five  minutes  after  the  bone  flap  has  been 
removed.  The  ease  and  expedition  with  which  the  extirpation  may  be 
performed  under  local  anesthesia  is  due  to  the  hemostatic  effect  of  the 
drugs  emjiloyed. 

In  all  our  cases  the  neuralgic  pains  disappeared  immediately  after 
the  extirpation  and  only  the  pain  of  the  wound,  which  could  clearly 
be  differentiated  therefrom,  persisted. 

CARE  OF  THE  WOUND  AND  AFTER-TREATilENT 

When  the  operation  is  over  and  the  brain  has  fallen  back  into  place 
the  bleeding  ordinarily  stops  of  itself  or  may  be  controlled  by  tempo- 
rary compression.  It  is  not  necessarj^  to  pack  the  cavity  with  gauze, 
unless  there  is  considerable  hemorrhage. 

The  amount  of  cerebro-spinal  fluid  which  comes  out  in  the  next  few 
days  from  injm-y  of  the  dura  is  usually  slight,  but  it  may  be  so  great 
that  the  dressing  will  require  changing  daily.  The  secretion  of  the 
fluid  gradually  slows  down  and  finally  stops  of  itself. 

The  convalescence  is  ordinarily  short.  The  majority  of  our  patients 
get  out  of  bed  from  the  seventh  to  twelfth  day  after  operation,  and 
are  discharged  on  the  eighteenth  to  twentieth. 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION- 


SSI 


The  two  cliief  dangers  of  the  operation  lie  in  the  hemorrhage  and 
in  the  pressure  to  which  the  hrain  must  be  subjected.  'J'his  latter  de- 
jjends  in  the  first  ])Iace  upon  the  retractor  upon  which  the  hrain  is 
lifted;  and  secondly  the  general  cerebral  pressure  is  increased  through 
secretion  of  cerebro-spinal  fluid.  This  one  may  prevent,  following  the 
suggestion  of  Tiffany,  by  making  a  short  transverse  incision  in  the 
upper  part  of  the  exposed  dura  to  give  exit  to  the  fluid. 

OTHER  METHODS  OF  EXTIRPATING  THE  GASSERIAN  GANGLION 

The  method  just  described  for  the  extirpation  of  the  ganglion  may 
be  called  the  temporal  method.     On  the  other  hand  Doyen  calls  his 


Fio.  283 
Doyen's  older  teclinic.     Incision. 

technique,  which  represents  a  transition  between  the  T.iicke-Kronlein 
method  arid  this,  the  temporo-sphcnoidal  method  (Fig.  283) .  He  per- 
formed his  o])cration  first  on  May  8.  1803,  while  this  mctliod  dates 
from  the  year  1892  (intracranial  resection  of  the  second  division),  and 
the  first  real  extirpation  of  the  Gasserian  ganglion  was  done  by  one  of 
us  (Krause)  on  the  31st  of  January,  1893.  The  patient,  who  is  now 
eighty-seven  years  old.  is  still  alive  and  Avithout  symptoms. 

According  to  the  tcchni(|ue  of  Doyen  the  skin  incision  should  not 
go  more  than  1.5  mm.  below  the  zygoma  and  should  avoid  all  the  facial 


252 


SURGERY  OF  THE  TRIFACIAL  NERVE 


branches.  The  accompanjang  pictures  will  explain  the  technique. 
After  separating  the  soft  parts  the  zygoma  and  coronoid  process  are 
temporarily  resected.    The   inferior   dental   and   lingual   nerves  are 


Fig.  284 
Doyen's  older  technie.     Bony  incision,  from  the  side. 

found,  divided,  and  the  central  ends  are  seized  in  a  clamp.  After 
the  internal  maxillary  artery  is  tied,  the  third  division  is  exposed  to  its 
point  of  exit  from  the  foramen  ovale.    Then  the  temporal  portion  of 


Fig.  285 
Doyen's  older  technie.     Bony  incision,  from  below. 

the  cranium  is  temporarily  resected,  the  base  of  the  flap  being  placed 
behind.  Xow  Doyen  removes  from  the  base  of  the  skull,  that  is  to  say 
the  horizontal  portion  of  the  greater  wing  of  the  sphenoid  and  the 


EXTIUPATIOX  OF  THE  GASSERIAN  GAXGLIOX 


253 


neighboring  portion  of  the  temporal  bone,  httle  bj'  httle  with  rongeurs, 
as  nnich  as  is  sliown  in  Figs.  284  and  •28.),  so  that  finally  the  foramen 
ovale  rejjrescnts  the  apex  of  a  triangular  opening. 

The  third  division  is  now  put  on  the  stretch  by  means  f)f  the  clamj), 
which  is  attached  to  the  inferior  dental  and  lingual  nerves  and  the 
dural  sheath  which  surrounds  tiie  ganglion  is  opened.  AVith  the  aid 
of  this  pull,  one  may  free  the  anterior  and  posterior  surfaces  of  the 
ganglion  with  the  elevator,  then  the  second  division  as  far  as  the  fora- 


¥lG.  2S(i 
Doyen's  older  tpclinic.     Exposure  of  the  ganijlion  and  its  branches. 

men  rotundum  and  the  first  division  as  far  as  the  orbital  fissure,  where 
they  are  divided.  Hereupon  the  ganglion  is  isolated  all  around,  while 
one  mobilizes  it  through  pull  on  the  nerve  trunks,  and  the  upper  edge 
of  the  petrous  portion  and  the  dural  sheath  which  surrounds  the  tri- 
facial root  itself  are  exj)osed  below  the  ])etrosal  sinus.  The  trifacial 
root  is  isolated  and  divided  centrally  on  the  posterior  surface  of  the 
petrous  portion  under  the  j)etrosal  sinus. 

jNIore  recently  Doyen  sacrifices  the  bone  flap  which  he  formerly  pre- 
served, and  carries  the  vertical  incision  farther  upward  through  the 
temporal  muscle  instead  of  forming  a  flap  with  a  pedicle  behind.  He 
also  makes  the  opening  in  the  skull  nuich  smaller  than  before  (Fig. 
280) . 


254  SURGERY  OF  THE  TRIFACIAL  NERVE 

The  first  technique  of  Doyen  has  been  modified  in  many  respects, 
thus  Lexer  makes  a  narrower  temporal  flap  in  order  to  avoid  the 
facial  branches  going  to  the  upper  eyelid.  Its  base  lies  in  a 
line  joining  the  outer  end  of  the  eyebrow  and  the  origin  of  the  lobule 
of  the  ear;  the  apex  in  a  line  joining  the  upper  edge  of  the  orbit  and 
top  of  the  concha.  The  z3^goma  is  chiseled  through  w^ithout  injiny  of 
the  soft  parts  covering  it,  the  coronoid  process  is  not  resected,  the  di- 
vided portion  of  the  temporal  muscle  is  turned  doAvnward.  Lexer  sac- 
rifices the  piece  of  temporal  bone  and  like  Doyen  removes  the  base 
of  the  skull  till  he  reaches  the  foramen  ovale.  The  brain  retractor  is 
used  only  in  freeing  up  the  ganglion.  Gushing  (Jour.  Amer.  ISled. 
Assn.,  INIarch,  April,  1905)  proceeds  in  a  similar  fashion. 

COMPARISON  OF  THE  VARIOUS  METHODS 

The  technique  of  Doyen  has  the  advantage  in  that  the  brain  does 
not  have  to  be  lifted  up  so  liigh  as  in  oiu*  method,  but  this  necessity 
does  not  always  arise.  The  third  division  can  be  exposed  without  dis- 
turbing the  dura,  but  this  is  only  the  beginning  of  the  operation  itself 
and  up  to  this  point  the  brain  has  only  to  be  lifted  slightly.  Every  one 
who  has  done  the  operation  on  the  living  knows  that  the  difficulties 
begin  only  after  ligation  of  the  middle  meningeal  artery.  From  this 
point  on  one  must  always  have  an  unobstructed  view  over  the  entire 
operative  field.  In  order  to  proceed  in  the  depths  between  the  base  of 
the  skull  and  the  dura  which  covers  this  and  to  be  able  to  expose  the 
cavum  jNIeckelii  completely  the  temporal  lobe  of  the  brain  must  always 
be  lifted  in  its  protective  coverings,  but  only  as  little  as  is  absolutelj' 
necessary.  This  can  be  entirely  avoided  by  no  method,  otherwise  one 
works  in  this  very  dangerous  region  by  sense  of  touch,  and  maj^  injure 
the  sinus  cavernosus,  the  internal  carotid  which  lies  within  it,  and  the 
three  motor  nerves  of  the  ej^e,  occurrences  which  happen  in  spite  of 
all ;  but  in  the  method  which  we  have  given,  they  need  not  be  frequent. 
JMoreover  with  this  procedure  there  can  be  no  question  about  true  ex- 
tirpation of  the  ganglion ;  partial  extirpation,  like  the  employment  of 
curette  and  similar  instruments,  should  be  condemned. 

In  order  to  limit  the  elevation  of  the  brain  to  the  slightest  degree 
possible,  the  lateral  wall  of  the  skull  should  be  removed  do^vn  to  its 
point  of  transition  to  the  base  of  the  skull,  that  is,  to  the  infratemporal 
crest.  Nevertheless  resection  of  the  zygoma,  particularly  in  the  Cau- 
casian race,  is  not  necessary  for  this  purpose.  Study  of  a  skull  sawed 
open  teaches  that  in  our  race  the  upper  level  of  the  zygoma  is  located 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION  255 

at  the  same  level  with  the  intracranial  opening  of  the  foramen  ovale, 
and  accordingly  it  does  not  limit  our  operative  field. 

We  have  j)racticed  every  modification  of  the  temporal  and  of  the 
sphenoidal  techin'ciue,  as  well  as  combinations  of  the  two  methods,  on 
the  cadaver  and  several  of  them  also  npon  the  living,  but  we  have  never 
been  persuaded  that  any  of  them  exposes  the  operative  field  so  com- 
pletely as  our  temporal  metliod.  Anatomical  investigations  u])on  the 
cadaver  do  not  shake  our  point  of  view.  For  the  one  thing  which 
renders  the  operation  so  difficult  in  the  living  is  venous  bleeding  from 
the  dural  veins,  and  in  a  narrow  approach  this  works  naturally  much 
more  disturbance  than  if  the  deep  wound  is  under  clear  view.  On  the 
other  hand  ligation  of  the  trunk  of  the  middle  meningeal  artery  ac- 
cording to  our  technique  is  so  safe  that  we  recommended  it  in  1892 
as  a  typical  operative  method  and  it  has  been  rejieatedly  performed 
with  residt  in  hemorrhage. 

Oiily  in  tlie  occasional  cases  in  which  the  intradural  pressure  is  par- 
ticularly high,  so  that  the  dura  and  its  contents  cannot  be  lifted,  it  may 
be  foimd  necessary  to  remove  the  base  of  the  skull  in  the  described 
manner.  One  must  then  first  cut  through  the  zygoma  siibcutane- 
ously  with  a  chisel  from  the  lower  ends  of  the  incision,  first  behind  and 
then  in  front.  It  is  a  matter  of  no  moment  whether  or  not  the  bony 
plate  is  high  or  low.  We,  therefore,  always  begin  the  extirpation  of 
the  Gasserian  ganglion  with  the  incision  shown  in  Figure  282. 

After  some  experience,  which  now  includes  eighty-one  extirj^ations, 
we  have  been  led,  under  conditions  of  normal  brain  tension,  to  prefer 
the  temporal  method  over  others.  In  increased  biain  tension  one  can 
puncture  the  dura  and  allow  the  cerebro-spinal  fluid  to  flow  out.  The 
procedures  of  Doyen,  Lexer  and  Gushing  are  of  value  in  extirpating 
tumors  from  the  middle  fossa,  as  well  as  for  tying  off  tlie  trunk  of  the 
middle  meningeal  artery  in  injuries.  Cushing  and  Lexer  make  the 
temporal  flap  lower  and  sacrifice  the  bone;  but  the  maintenance  of 
this  guarantees  a  level  and  hardly  noticeable  scar. 

INDICATIONS 

If  on  account  of  the  severity  of  the  pain  an  intracranial  operation 
becomes  necessary,  extirpation  of  the  ganglion  and  of  the  trifacial 
root  is  alone  to  be  considered.  As  a  "ulc  one  does  not  resect  intra- 
cranially  the  single  divisions,  as  this,  like  peripheral  resection,  empiri- 
cally allows  more  chance  for  recurrence,  and  from  the  point  of  view  of 
danger  they  do  not  stand  far  behind  the  radical  operation. 


256  SURGERY  OF  THE  TRIFACIAL  NERVE 

Ordinarily  the  extirpation  of  the  ganglion  should  be  undertaken 
only  if  alcohol  injections  and  the  less  extensive  operations  are  without 
result.  But  as  advances  in  technique  lessen  the  danger  more  and  more, 
we  will  undoubtedly  come  at  some  time  to  the  point  where  we  will 
undertake  the  radical  operation  first  of  all.  For  it  is  unsatisfactory  to 
advise  peripheral  resection  in  severe  cases,  when  we  can  expect  only 
temporary  relief. 

If  the  cause  of  the  neuralgia  can  be  placed  in  changes  in  the  Gas- 
serian  ganglion  or  the  trifacial  root,  a  diagnosis  which  may  be  estab- 
lished, naturally  the  intracranial  operation  must  be  considered  from 
the  first. 

In  considering  diagnosis  we  have  already  mentioned  the  neuralgias 
which  occur  in  the  region  of  the  recurrent  branches  which  supply  the 
dura  mater  with  sensory  fibres.  The  recurrent  nerve  from  the  third 
division  alone  comes  off  in  the  foramen  ovale  or  just  below  it,  and  so 
can  be  extirpated  by  one  of  the  extracranial  methods,  which  we  have 
described,  for  finding  the  third  division  at  the  base  of  the  skull.  One 
may  succeed  in  this  waj^  even  in  removing  a  small  portion  of  the  gan- 
glion from  below. 

But  on  the  other  hand  the  recurrent  branches  of  the  first  and  sec- 
ond divisions  have  their  origin  within  the  cranial  cavity  and  may  be 
reached  only  by  the  intracranial  technique.  To  be  sure,  in  the  extraor- 
dinarily severe  one-sided  and  deep-seated  headache,  such  as  is  observed 
in  severe  trifacial  neuralgia,  not  alone  the  three  reciu'rent  branches, 
but  at  times  also  the  meningeal  branch  of  the  ethmoid  nerve  which 
inervates  the  dura  mater  in  the  region  of  the  anterior  fossa  and  the 
forehead  is  also  envolved.  The  etluiioidal  nerve  may  be  found  in  the 
orbit,  as  shown  on  page  215. 

INTRACRANIAL  RESECTION  OF  THE  THIRn  DIVISION 

Very  exceptionally  this  operation  may  have  to  be  considered  if  in  a 
severe  recurrent  trifacial  neuralgia  the  nerve  has  been  comjjletely  re- 
moved outside  the  cranial  cavity  and  age  as  well  as  the  condition  of  the 
patient  do  not  allow  of  extirpation  of  the  ganglion.  Although  intra- 
cranial resection  of  this  nerve  trunk  is  no  guarantee  against  recur- 
rences, nevertheless  in  old  persons  one  may  hope  for  freedom  from 
pain  for  the  rest  of  their  days.  If  this  plan  is  decided  upon,  the 
lateral  bony  plate  need  not  be  cut  away  so  high  as  for  the  temporal 
method  of  extirpation  of  the  ganglion.    Tlie  following  case  will  serve 


Krause-Hevmann-Elirenfried. 


Tab.  54. 


Intracranial  resection  of  the  third  division. 


Middle  meningeal  artery 


Zygoma 


Temporal 
muscle 


Fig.  287.  The  skin-muscle-bone  flap  has  been  turned  down, 
and  the  zygoma  is  being  chiseled  through. 


Fig.  288.  Chiseling  a  wedge  out  of  the  base  of  the 
skull,  with  its  apex  at  the  foramen  spinosum. 


Middle 
meningeal 
artery,  at 

point  of 
origin  from 

internal 
maxillary 


Temporal  muscle 


Zygoma 


Fig.  289.  Middle  meningeal  artery 
tied  and  cut. 


///  division 


Middle 
meningeal 
artery,  tied 

and   divided 


Fig.  290.  Chiseling  open  the  foramen  ovale, 
and  exposure  of  the  3^^  division. 


Rebman  Company,  New  York. 


INTRACRANIAL  RESFXTION  OF  THE  THIRD  DIVISION    257 

as  an  example;  the  operation  was  carried  out  in  a  similar  manner  ex- 
cept for  sacrifice  of  the  temporal  hone  hy  Qwtim  in  IHOi. 

A  seventy-five-year-old  man  had  heen  operated  uj)on  four  times  hy 
others  for  left  facial  neuralgia  in  the  distrihution  of  the  third  division, 
and  two  years  hefore  had  been  operated  on  hy  us  hy  sawing  through 
the  ramus  of  the  lower  jaw  and  resecting  the  third  division  at  the  fora- 
men ovale.  For  a  year  and  a  half  thereafter  he  was  without  pain. 
Then  a  recurrence  set  in  which  disappeared  again  after  a  few  days. 
Six  months  later  it  came  back  much  worse  and  resisted  all  methods  of 
treatment.  Thereupon  the  patient  begged  that  he  might  be  operated 
upon  under  any  circumstances  since  he  could  not  bear  the  suffering, 
and  in  spite  of  his  age  and  the  advanced  arteriosclerotic  heart,  oj^era- 
tioii  was  determined  upon. 

We  expected  that  intracranial  resection  would  give  relief  for  an- 
other two  years,  in  case  the  condition  of  the  patient  did  not  allow  of 
extirpating  the  ganglion.  The  zygoma  was  resected  osteoplastically 
and  turned  downwai'd  and  a  three-cornered  piece  was  chiseled  from 
the  base  of  the  skull  in  the  neighborhood  of  the  middle  fossa,  the  base 
of  which  was  external  and  the  apex  at  the  foramen  ovale  (see  Fig. 
28.5). 

The  temporal  flap  was  made  in  the  ordinary  way  (see  Fig.  287, 
Plate  54 ) ,  not  going  quite  so  high  as  usual.  The  incision  went  at 
once  through  skin,  fascia  and  temporal  muscle  down  to  bone,  and  the 
periosteum  was  stripped  away.  After  a  hole  was  made  at  the  upper 
edge  with  a  drill  the  dura  was  freed  up  with  a  Braatz  guide  and 
the  bone  divided  with  the  Dahlgren  rongeurs  in  the  line  of  the  cut. 

After  control  of  the  hemorrhage  the  temporal  muscle  was  divided 
from  the  anterior  and  posterior  corners  of  the  wound  downward  to  the 
zygoma,  during  which  ])roeedure  the  temj)oral  artery  was  divided, 
both  ends  seized  and  tied  off.  Hereupon  a  sharp  retractor  was  })laced 
in  the  temporal  muscle  to  draw  it,  together  with  the  bony  plate,  down- 
ward; and  the  zygoma  was  chiseled  first  behind,  then  in  front  in  typical 
fashion,  as  in  the  Liicke-Kroidein  operation  (see  page  222  and  Fig. 
2.'5.'5)  and  likewise  pulled  downward  with  the  retractor.  Then  the  dura 
was  freed  up  inside  from  the  base  of  the  skidl  and  likewise  the  soft 
parts  below  from  the  base  of  the  skull,  and  the  bony  wedge  just  de- 
scribed was  removed  with  the  rongeurs  and  chiseled  down  to  the  fora- 
men spinosum.  The  middle  meningeal  artery  now  lay  exposed  as 
well  as  the  upj)er  part  of  the  internal  maxillary  artery  from  whicii  it 
arises  (Fig.  288,  Plate  .'54). 


258  SURGERY  OF  THE  TRIFACIAL  NERVE 

Now  with  a  half  pointed  sharply  bent  elevator  the  middle  menin- 
geal artery  was  lifted  out  of  its  canal,  a  clamp  applied  close  to  the 
diu'a  and  a  catgut  ligature  placed  around  it  below  the  clamp  and  tied. 
The  clamp  was  removed  and  the  middle  meningeal  artery  cut  through 
at  this  point  (Fig.  289,  Plate  54)  after  the  bony  bridge  between  fora- 
men spinosum  and  foramen  ovale  was  cut  away  with  a  narrow  chisel, 
the  third  division  lay  absolutely  free  (Fig.  290,  Plate  54),  and  could 
be  pried  out  of  the  foramen  ovale  with  a  bent  elevator.  On  account 
of  collajise  of  the  patient  the  exposure  and  removal  of  the  Gasserian 
ganglion  could  not  be  performed.  Accordingly,  the  third  division 
was  seized  with  a  toothed  clamp  and  separated  from  it  obliquely  with 
a  tenotome,  and  as  the  peripheral  portion  could  not  be  twisted  out  on 
account  of  the  scar  resulting  from  the  previous  resection,  it  was  cut 
away  as  far  as  possible  in  the  scar  tissue.  Fully  2  cm.  of  the  nerve 
could  be  removed. 

The  hemorrhage  was  moderate.  A  drain  was  placed  in  the  posterior 
corner  of  the  woimd.  The  zygoma  was  replaced,  sewed  in  front  and 
back  with  periosteal  sutures  of  catgut  (see  Fig.  253),  the  bony  plate 
was  sewed  above  with  three  periosteal  catgut  sutures,  and  the  skin 
wound  was  closed  with  interrupted  silk. 

The  wound  healed  well,  the  drain  was  removed  on  the  third  day, 
and  the  patient  got  up  on  the  fifth  day.  The  operation  freed  him 
completely  from  pain,  but  he  died  a  few  weeks  after  discharge  from 
influenzal-pneumonia. 

EESECTION  OF  THE  TRIFACIAL  ROOTS 

An  attempt  had  been  made  by  others  one  year  previously  in  a  fifty- 
six-year-old  woman  to  extirpate  the  Gasserian  ganglion  by  the  tem- 
poral method.  ^Microscopic  examination  of  the  removed  part,  as  we 
were  informed,  showed  only  dural  tissue,  but  no  nerve  elements.  Since 
the  dura  should  not  be  removed  in  this  operation,  the  procedure  could 
not  have  been  rightly  carried  out. 

The  incision  was  made  around  the  old  scar,  but  in  order  not  to  in- 
jure the  dura  the  skin  was  shoved  back  a  bit  above,  and  the  periosteum 
was  incised  and  stripped  backwards  from  the  bone.  The  skull  was 
exposed  around  the  old  trephine  opening  and  a  wide  elevator  was  laid 
carefullj'  in  the  anterior  upper  edge  of  the  old  flap  between  dura  and 
the  bony  plate,  and  this  was  pried  away  from  the  dura  until  the  index 
finger  could  be  inserted.  With  this  the  bony  plate  was  freed  from 
the  dura  and  turned  do^vnward  (Fig.  291,  Plate  55),  after  the  old 


Krausc-Heyinann-Ehrenfricd. 


Removal   of  the  trifacial   root. 


AVti'  />orfv  if!Cf\ii>i 


Tab.  55. 


Middle  fossa 


Neiv  bony  incision 

Fig.  291.   The  skull  is 
opened  in  the  old  scar. 


Middle  meningeal 
(irteiy 


Fig.  292.   Tiie  dura  is 

freed  up  from  the  middle 

fossa  inth  the  finger. 


Trifacial  root^ 


Superior  margin  oj 
petrous  portion  — 


Fig.  293.  The  middle 

meningeal  artery,  of 

unusual  size  is  exposed. 


I'oramen  i.pinosnm  Anterior  surface  of  petrous  portion 

Fig.  294.  Tiie  trifacial  root  is  torn  through  at  superior  margin  of  petrous  portion. 


Rebni.in  Company,  New  York. 


RESECTION  OF  THE  TRIFACIAL  ROOTS  259 

scars  in  front  and  behind  were  split  downward  to  the  zygoma.  In 
tuniing  the  Hap  down  it  appeared  that  the  temporal  fossa  had  not 
broken  away  low  enough  at  the  tirst  operation  and  presented  a  con- 
siderable obstruction  to  proceeding  into  the  middle  fossa.  The  im- 
portance of  this  we  have  already  shown  (see  p.  240).  A  bony 
strip  more  than  1  cm.  wide  had  still  to  be  removed  from  the  lower  edge 
of  the  opening  with  rongeurs.  As  the  bony  opening  was  limited  in 
front  also,  a  ereseentic  strip  about  1  cm.  wide  was  removed  here.  In 
these  manipulations  we  succeeded  in  loosening  away  the  adherent  dm'a 
by  blunt  dissection  without  injury. 

We  made  our  way  extradurally  into  the  middle  fossa,  using  small 
sponges  held  by  smooth  forceps  (see  Fig.  277,  Plate  53),  a  wide  ele- 
vator or  the  index  finger  in  turn.  The  dura  was  very  closely  adherent 
to  the  base  of  the  skull.  After  it  was  loosened  in  this  manner  for  1 
cm.,  the  rest  of  the  process  was  carried  out  with  the  index  finger 
(Fig.  292,  Plate  .5.5)  and  with  some  pains  we  succeeded  in  reaching 
the  foramen  spinosum.  Bleeding  was  considerable,  but  could  be  con- 
trolled by  temporary  packing.  In  separating  the  dura  further,  which 
had  to  be  done  with  small  sponges,  it  showed  itself  to  be  under  strong 
tension,  so  that  it  yielded  very  little.  In  the  de])ths  the  middle  menin- 
geal artery,  which  was  of  unusual  size,  came  into  view  (Fig.  293,  Plate 
55).  In  exposing  it  further,  it  tore  in  one  small  place,  and  a  dis- 
turbing hemorrhage  ensued,  which  Avas  controlled  by  compression  un- 
til the  vessel  could  be  seized  with  a  hemostat  and  tied  in  the  regular 
manner.  As  a  result  the  patient  collapsed,  and  the  wound  cavity  was 
packed  loosely  with  vioform  gauze,  the  bony  flap  sewed  into  place,  and 
the  operation  interrupted. 

P"'ive  days  later  we  completed  the  operation.  Since  the  diflRcultj'^ 
in  loosem'ng  up  the  dura  from  the  base  of  the  skull  had  been  great 
up  to  this  poitit,  and  had  increased  markedly  in  the  region  of  the  Gas- 
serian  ganglion,  we  jjroceeded  from  the  foramen  spinosum  and  the 
ligated  middle  meningeal  artery  backward  to  the  anterior  surface  of 
the  petrous  portion  instead  of  medially  to  the  third  division.  At  this 
point  the  dura  could  be  lifted  up  without  marked  bleeding,  and  pro- 
ceeding medially  and  backwards  along  its  surface  we  could  finally  see 
clearly  the  upper  edge  of  the  petrous  portion.  Here  we  met  consid- 
erable venous  hemoirhage,  evidently  from  the  torn  superior  petrosal 
sinus,  which  was  cf)ntrolled,  however,  by  gauze  compression  with  the 
assistance  of  the  brain  retractor.  Xow  proceeding  carefully  toward  the 
middle  line  along  the  upper  margin  of  the  jjetrous  portion,  at  a  depth 


260  SURGERY  OF  THE  TRIFACIAL  NERVE 

of  6  cm.,  measured  from  the  surface  of  the  skin,  we  came  upon  the  tri- 
facial root,  exactly  at  the  place  where  it  passed  from  the  posterior  to 
the  middle  fossa.  With  the  assistance  of  various  blunt  hooks  it  could 
be  isolated  in  its  canal  covered  by  the  origin  of  the  tentoriun  and  the 
dura  mater,  and  seized  with  the  nerve  clamp  (Fig.  294,  Plate  55) .  By 
careful  twisting  a  piece  about  2  cm.  long  could  be  removed.  No  bleed- 
ing of  any  significance  ensued,  although  a  small  branch  of  the  basilar 
artery  ordinarily  accompanies  the  trifacial  root. 

A  small  drain  was  placed  in  the  cavity  from  behind  forwards  in 
order  to  carry  off  the  blood  which  might  ooze  out  later,  otherwise  the 
wound  was  sewed  tight.  The  drain  was  removed  on  the  fourth  day 
and  healing  followed  without  incident. 

In  this  case  we  went  too  far  backwards  to  expose  the  Gasserian 
ganglion,  M-hich  had  probably  been  left  intact  at  the  previous  opera- 
tion. 

Frazier  of  Philadelphia  advocates  division  of  the  sensory  root 
through  a  small  trap  door  just  above  and  in  front  of  the  ear,  over  avul- 
sion of  the  ganglion.  He  claims  that  it  is  attended  with  less  hemorrhage, 
that  it  does  not  expose  to  injiu'y  adjacent  structures  such  as  the 
cavernous  sinus  and  the  three  cranial  nerves  in  juxtaposition  to  it, 
that  in  rare  cases  one  may  preserve  the  motor  root,  and  thus  the  func- 
tion of  the  muscles  of  mastication,  and,  finally,  that  there  is  less  likeli- 
hood of  ulceration  of  the  cornea.  But  in  our  experience  division  of  the 
sensory  trifacial  root  appears  to  be  no  easier  than  extirpation  of  the 
Gasserian  ganglion,  and  as  this  operation,  as  we  have  shown  on  page 
244.  has  no  advantage  in  regard  to  neuro-paralytic  keratitis,  the  typi- 
cal extirpation  is  alwaj's,  in  our  opinion,  to  be  preferred. 


INDEX 


Abscess,  subperiosteal,   168 
Al)sorb('iit  cotton,  68 
Adiilin.  .'i 

Adiiesivr  stiapsi,  68 
Adrenalin.   2'> 
Aftcr-tnatnu'nt.  68 
Airiil   paste.   133 
Al.oliol.  .i.  57,  02.  68,  86,  166 

injection,   207.  2')(i 
Lange  metluxl.   207 
.SdilossiT   mi'tlidd.  207. 
AUoIiolics.    14.    11).  20 
Aluminum  bronze  wire,  61 
Amaurosis,  l.')4 
Ammonium  sulphate,   57 
Anesthesia,  chlorofrom,  16,  75 

conduction,  30,  31 

general.  34 

infiltration,    30 

inhalation.  1() 

intravenous.   10 

local,   10,  20,  33 
technique  of,  36 

of  deep  tissues,  36 
superficial  tissues,  36 

rectal,   10 

special  procedures,  39 

spinal.  10,  24,  26 

superficial.  30 

vomitiuf;;  after.  74 
Anesthetic,  selection  of,   13 
Ancsthol.    1!) 

Anesthetometer   (Connell's),  19 
Angioma  cavernosum,  92 

lipojtenous.    92 
Antrum,  mastoid,  opening  of,  168 

openinj}  a  sin.u'le.  183 
Kfister  method.   183 
method  of  Tartsch,  185 

operations  on,   183 

unilateral  empyema  of,  183 
Antisepsis.   4S 
Antito.xin.  diphtheria,  6 
Anus,  posture  in  operations  on.  8 
Arterio-sclerosis.  altectinf;  post\ire,  8 
Artery,  middle  meninjieal,  236 

li^ration  of,  246 
Asepsis,   48 

of  the  skin,   .")1 
Aseptic  rej.'uIations  during'  (i])erations,  63 
Atropin.  10.  73 
Auricul(>temi)oral  nerve,  228 
Autoclave,    53.   57 
Autotransfusion,  72 

Backhaus  damp,  63 

Balsam  of  Peru.  71  ■ 

Bandage,   manytailed.  60 

Bayonet  chisel.   168 

Beans,   in  auditory  canal,   166 

Belloque    cannula.    180 

Benzine.  54,   08,   7!) 

Bier's  method,  24,  46- 


Bile-duct,  9 

Bladder.  9 

Blake  ether  cone,  20 

Blankets,  electric,  72 
warmed.  72 

Bleplinroplasty.    151 
Indian   method,   151 
Lanfrenbeek  nii'thod.   151 
Szym.mowski   modification,    151 

Blood,   transfusion   of.  72 

Bone,  local  anesthesia  of.  30 

Boothby  <;as-o.\ygen  machine,  23 

Boric  acid.  5.  55,  165 

Braatz  Re|)arator.  44 

Braun's  procedure,  .32,  36 

Bromids,  73 

Broth,  2 

Bruns'  method.    194 

Bulb,  enucleation  of,  154 

Burow's  modification,  99 

CadwcU-Luc  method,  183 
Caflfeine.  17.  71 

sodiobcnzoate.  71 
Calcium  chlorate,  3 
Camphor,  17,  71 
Carbolic  acid.  58 
Carbon  dioxid.  18.  20 
Carbuncle,  88 
Carcinoma.  118,  122,  145 
Cardiac  weakness,  71 
Carlsl)ad   salts,   5 
Cascara,  76 
Castor  oil,  5,  76 
Cataract.  154 
Catgut,  59.  61 
Catharsis,  6.   76 
Catheterization.  77 
Cavum  Meckelii,  248 
Celoidin.  61.  HI 
Cerebellum.   8 
Cerumen.  165 
Cheek,  pliisti(   ojx'ration  on,  145 

Bardinliuuer  method,  146 
Chemical   cleansing,  51 
Choloroform.   10 

s^'quehc  of,    12 
Cigarette  drain,  65 
Cin'ulation.  restriction  of,  72 
C'hnidiiis  method.   61 
Cleft  palate.    134 

method  of  Bropiiv,   139 
Ilelbing.    139 
Langenl)eck,   135 
Cocain.  30.   35 

substitutes,  30 
Codein.   3 
Colfee,    75 
Collodion,    111 
Coma.    diMl)etic.    4 
Compliiations.  special,  71 
Conjunctiva,    154 
Corpus  adiposum  malic,  232 


263 


264 


INDEX 


Corrosive  sublimate.  5 
Cunniiigliam  elevator,  9 

Dental   nerve,   22!) 

Mikulicz   teebnique,  229 

modifications  in  technique,  233 
Dermoplasty,  iiS 
Diabetes,  3,  89 
Diet,  1 
Digalen,  71 
Disturbances,  gastric,  74 

intestinal.   74 

of   the  bladder,   77 
Drainage.    04 
Dressing.  fiS 

changing  of,  C9 

citrate,   90 

salt.  90 

sterilization  of.  .">6 
Drug  treatment.  3 
Drugs,  subcutaneous  injection  of,  3 

Ear,  Ifil 

epithelial  growth   in.   164 

foreign   bodies  in.   165 

middle,  purulent  inflammation  of,   166 

spoon,   16.5 

wax,   165 
Eburnizalion.  173 
Ectropion.  152 
Embolus.  73 
Endoneural  method  of  Crlle,  32 

C'ushing,  32 

Matas,  32 
Enema.  5,  76 

nutritive,  2,  75 
Entropion.   153 

Epidermis,  transplanting  of,  110 
Epithelioma.  118 
Esmarch  bandage,  32 

method,  46 
Ether,  1,   10.   18,  54,  68,   176 

in  minor  surgerv.  20 

"rausch."   21.   91 

sequel*  of.   12 

Sudek  method.  21 
Ethmoid,  exposure  of,  190 

radical  operation  on,   190 
Etbylchlorid.  24,  30 
Eustachian  tube,  236 
Examination  of  patient,  1 
Extremities,  45 
Eye,  154 

Face,    8 

cancer  of,  118 

malignant  tumor  of,  96 

operations  on.  41 

plastic  operation  on,  98 

tumor  in  the  tissue  of,  91 
Facial  protector  of  Stacke,  174 
Fascia  transversalis,  39 
Feeding,  artificial,  75 
Fibro-epithelial  tumor.  91 
Fibroma,  91 
Flannel   boot,  9 
Flap  grafts,  100,  103 

Indian  method.  101 

Italian  method.    104 

Tagliacotian  metliod,   104 


Flaps,  free  transplantation  of.  108 

after  extirpation  of  malignant  growths,  117 

Foramen  ovale.  234 
rotundum.   221 

Forehead,  8 

Formalin,    57 

Freezing,  30 

Frontal  nerve,  213 
resection  of,  213 

Fuchsin  ointment,  90 

Furuncles.  8.5,   164 

Furunculosis,  86 

Gag,  136,  237 

Gas  ether  sequence  apparatus.  22 
Gasserian   ganglion,   extirpation  of,   42.  239, 
251 
after-treatment,  2.50 
care  of  wound,  250 
comparison  of  various  methods,  254 
convalescence,  250 
indications,   255 
method  of  Cusliing,  254 
Doyen,  251 
Heidenhain.  239 
Horsley.   244 
Krause.   249 
Lexer.   254 
LiickeKriinlein,   251 
Wagner,  239 
preparation  for,  242 
remarks  on  technique,  245 
Sultan's  experiments,  244 
Tiffany's  suggestion,  251 
manipulation  of.  247 
Gauze,  57,  65.  79 
Gelatin,  0 
Glycerin,  52,  71,  76 
Gowns,   57 

steri'e,  63 
Grafting,  "pin-point."  108 

Wolfe-Krause  method,  112 
Grafts,   100 

pediculated,   121 
Grape  sugar,  75 
Grossich's  technique,  54 
Growths,  benign,  91 
small,  91 

Hackenbruch  method.  31,  36 
Haertel's  method.  44 
Hands,  disinfection  of,  50 
Harelip,  double,   130 
in   infants,   132 
plastic  operation  for.   127 
incision  of  Dieffenbach.  129 

Wolfe,   130 
method  of  Bardclebcn,  131 
Graefe,   128 
Malgaigne.   128 
Mirault,   128 
N«aton,  128 
Head,  surgery  of,  79 
Heating  pads.  72 

Heidenhain  hemostatic  suture,  62,  245 
Heister  mouth  gag.  237 
Hemangioma.  92 
"creeping,"  93 
racemose  arterial,   93 
simplex,  93 


INDEX 


265 


Ilimofrlotiincmia,  "It 

llfiiiorrlia;.'!-.  voiious.  247 

Hi>ilifiif};^'s  mctlidils,  its 

Honey,    71! 

HoriTKinal.  7I> 

Horsi'liaii",  nit,  01 

Hot  water   bags.  72 

Hydrastis,  (> 

FJydro'/eii  dioxid,  .'>.  71,  228 

Hyperemia.  80 

"Bier's.  SS 
Hypertrophy,  prostatic.  7 
Hypopliysisi  method  of  Hirsch. 


195 


lee  pills,  7>'> 

Inferior  dental  nerve.  22!» 

Infraorbital  nerve.  217 

reseetion    of.    217 
Instruments,   sterilization   of,   oO 
Iodine,  .'■>4,   ."iS,   f.3,   70 
lodinepotassium-iodide,  01 
Iodoform.  .5S,  70 

gauze,    170 
Irradiation,   108 

Jugular  vein,  ligature  of.   174 
Juillard  mask.  2n 

Keratitis  neuroparalytiea.  243 
Kesselbaoh's  spot,   ISO 
Kidney,   8,    14 
Killian   operation,   187 
Kuhlenkampf  method.  45 

Lamineetomy,  40 

Lange  method,  207 

Laparotomy.  ,3."> 

Laughing  gas.  22 

Legumens,   160 

Lexer's  technique.  22.5 

Lids,  edema  of,  17.1 

Linen,  •")7,  01 

Lingual  n.Tve,  227,  220 

Lip,  extirpation  of  cancer  of,   122 

plastic  restoration  of,  from  cheek,  123 
Lipoma,  01 

Lister's  carbolic  spray,  48 
Lithotomy.   8 
Lockjaw,  145 
Lumbar   puncture,  28 
Lupus,  117 
Lysol,  5 

Magnesium   sulphate,  .')7 

Massligatiires.   07 

Mastoid   cells,   opening  of,   107 

operation,  radical,    171 

process,  108.  171 
Mastoiditis.   107 
Maxillary  division,  superior.  217 

inferior,  227 
Medication.  3 

Meningeal  artery.  230.  240 
Mercury,  salts  of,  02 
Methvlenc  blue.  51 
Milk,'  2 

malted,  75 
Molasses,  76 
Morphine,  2,  3,  14,  10,  10.  73,  242 


Mouth  gag,  237 

Mucous  membrane,  disinfection  of,  55 

Mull,  coarse,   111 

Myrrh,  71 

Narcotics,   2 

Nausea,  75 

Nerve,  extraction,  200 

Thierscli  method,  200 
facial,  171 
paralysis,  175 

trunks,  large,  blocking  of.  37 
Neuralgia — are  Trifacial  nerve. 
Neuralgia,  trigeminal.  2 
Neuralgic  jjaiiis.  107 
Nitrous  ox  id,   10,  22 
Non-carbonated  waters,  5 
Nose,   accessory  sinuses,   179 
iiijuiies  of.    170 
plastic  o|)erations  on,  130 
Indian  metho<l,    140 
Israel's  metliod,    141 
Italian  method.  140 
Kiinig's  method.  140,  145 
Lexer's  method.   143 
spontaneous  bleeding  from,  180 
surgery  of,    170 
tortuous  passages  of,  179 
Novocain,  25,  31,  33,  35,  46,  208 

Oat  meal,  5 
Obi'rst  method,  31 
Oil,  sterile,   75 
Operating  room,  0 

table,    7 
Operation,  preparation  for,  1 

contraindications  to.  0 
Ophtlialmic  division,  213 

branches,  215 
Opium,  2 
Orbit,   \'>i 

cellulitis  of,  102 

exenteration  of,  154,   156 
Kiistcr's  metliod,   150 
with   preservation   of   lids,    150 
with  removal  of  lids.   157 

resection  of  tem])oral  wall  ( Krijnlein's) ,   100 
Kochcr   moditication,   100 
Orbital   nerve,  220 

resection  of,  220 
Otitis  media  purulenta,   107 
Oxvcvanate  solution,  51,  57,  64 
Oxygen,  22 

Packing,  70 
I'ainful  points,  107 
Pause  K<irn<'r  plastic  procedure.  172 
Pantopon,  15,  73 
Paquelin  ca\itery,  30,  180 
Paracentesis.    100 
Parallin,   7.'! 
Peppermint.  75 
I'epsin — fibrin — peptone.  70 
Perineal  operations.  0 

Peri])liiTal  operations  on  the  trifacial  nerve, 
208 

prognosis,  212 

reault,  212 


266 


INDEX 


Peristalsis,  70 

I'l'iitoiu'uni.  ."iO 

l'lilcl)itis,  i)unili'nt.  174 

I'liL-lgmoii,  incision  of.  84 

Phvsostijiniiiic  siilicjlate,  76 

Pi  Hows,   8 

Plaster  of  Paris.  GO 

Plastic  procedures,  special,  121 

Pneumonia,  T3 

post-operative,  35 
Posture,  7 

Potassium  bromid,  3 
Preparation   for  operation.   1 

fieneral.    1 

in  diabetics.  3 

of  si)ecial  regions,  5 

special,  3 
Pyemia,  H7,  174 
Pylorus,  stenosis  of,  2 

Rectal   injections.  2 
Rectum,  posture  in  operations  on,  8 
Respiration,  artificial.   IS 
Respiratory  f;v""">stics.  74 
Rhinoi)lastv,  loi).  140 
Ribs,  9 
Rolls,  8 

Rose  position.  130 
Rubber   dam.  G'l 
gloves.  o2 

Salt  solution,  2,   17,  4B,  72,  207 

Sandbags,   8 

Scarlet  red.  ointment  of.  71.  00 

Schleiclrs  infiltration  nn-lliod.  31,   33 

Schloffer's  teclini(|ue.  liH 

Schlosser's  metliod,   207 

Scopolamin.   14.   2(> 

Sebaceous  cysts,  01 

Septic   processes,   84 

Septum,  deviations  of.  170 

resection  of    (Killian'sl,   19.5 
Sheets,  disinfection  of.  ^u 
Sigmoid  sinus,  jilili'liitis  of.  174 

thrombosis  of.  174 
Silicate  bandage.  00 
Silk,   50.  62 
Silkworm  gut.  50.  01 
Silver  nitrate.   ISO 
Sims   position.   8 
Sinuses  accessory,  181 

chronic  inflammation  of.  ISl 
purulent  inflammation  of.  181 
serocatarrlial  inflammation  of.  181 
suppuration  of.  182 

cavernosus.   175 

frontal.    ISO 

splienoiilal.  exposure  of.   191 
Skin,  disinfection   of.  49 

grafts.  90 

mechanical  cleansing  of.  50 
Skull,   S 

bullet  wouiuls  of.  84 

cimitiouiul   fractures  of,  SO 

resection   at  the  base  of.   230 
Soda   bicarbonate.   4,   28.   50.   100 
Soft  parts,  circular  injection  of.  39 
Spinal  fluid.  27 


Spine,  posture  in  operations  on,  8 

Sponge,  sterile,  54,  57 

Stab-needle.  137 

Stacke  teehni(jue.    171 

Starch  bandage.  CO 

Stimulants.   18 

Stomach,   dilated.  2 

Stovain,  24,  27 

Strychnine,   17,  27 

Sublimate,  51 

Suction  cup,  80 

Sulphonal.  3 

Supramastoid  crest.   173 

Suprarenal  gland,  extract  of.  32 

Suprarenin.  32.  35.  38,  40.  05.   170 

Suture  material,  emjiloyment  of.  GO. 

sterilization   of.   5(i,  50 
Swathe,   00 

Tea,   2,    75 

Technique,   general   surgical.   1 
Tetany,  2 

Tlu'rmocautery,  07 
Thirst,   75        ■ 

Tliorax,  posture  in  operation  on,  8,  9 
Throml)Osed  vessels,  175 
Tliromliosis,   73,   174 
obstructing,   174 
parietal,   174 
Tying  of  vessels,  07 
Tobacco,  2 

Towels,  sterilization  of.  57 
Trendelenburg  position,  7.  25,  27 
Trephining,  40 
Trichloracetic  acid.  180 
Trifacial  nerve,   107 

determination   of  affected  brancli.   199 
accompanying  manifestations.  202 
first  or  oplithalmic  division.  213 
intracranial  resection  of  the  tliird  division, 

250 
irradiation  phenomena,   108 
neuralgia,  alcohol  injection  in.  207 
central  seat  of,  205 
diagnosis.  203 
etiology,    203 
general  treatment.  20G 
peripheral  seat  of,  205 
prognosis.  203 
relapses.  202 
termination  of.  202 
resection  of  at  base  of  skull,  234 
method  of  Kocher,  235 
Krfinlein,  234 
Liicke,  234 
Pancoast.   234 
resection  at  foramen  ovale,  234 

method  of  Liicke,  234 
second,  or  superior  maxillary  division,  217 
Kocher's  incision,  217 
method  of  Braim.  227 
KWinlein,   225 
Lexer,  225 
Lossen,   227 
Liicke,  227 
variations  in  technique.  224 
simultaneous    resection    of    the    three    di- 
visions,  238 
third  or  inferior  maxillary  division,  227 


INDEX 


267 


Trifacial  roots,  roseotion  of,  2r)8 
Frazier's  recommendation.  200 
Trional,  3 
Tropocooain.  24.  27 
Tympanic  cavity,  Itifi 

Ureter,  posture  in  operations  on,  8 
Urine,  examination  of,  ,3 
Urotropin,   » 
Uterus,  e.\tirpation  of,  2G 

Vaccine,  in  chronic  furunculosis,  87 

Vagina,  posture  in  operations  on,  8 

Venous   licmorrha<i;e,   247 

Vein,  filled,  in  septic  thrombosis,   175 

Veronal,  .3 

Vessels,  circuminjection  of.  37 


Vioform.  oS 

Wadding,  in  dressings,  68 

Wi-rtlu'im  extirpation  of  the  uterus,  26 

Wire,  5!),  01 

Wliitehead  gag.   130 

Wound,  care  of,  64 

edges,   care  of,   60 

infected,   84 

of  the  head,  7!> 
soft  parts,   7!> 

pain  in,  73 

X-ray,  81.  84,   10.->,  118,   155,   184 
Yeast,  in  furunculosis,  87 


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